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AN  \ELEMENTARY  TREATISE 


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PRINCIPLES  OF  TOKOLOGY  AND  EMBRYOLOGY, 


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BY 


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ALF.  A.  I..  M.  VELPEAU,  XIII.D. 

ETC.  ETC. 


TRANSLATED   FROM   THE    FRENCH   BY 


OB.  D.^MEZOS,  M.D. 

Member  of  the  American  Philosophical  Society ;  Lecturer  on  Midwifery  and  the 
Diseases  of  Women  and  Children,  &c.  &c. 


PitlatreliiiiCa: 

JOHN  GRIGG,  No.  9,  N.  FOURTH  STREET. 
1831. 


u 


%     *. 


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It2l 


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Eastern  District  of  Pennsylvania,  to  wit : 

Be  it  remembered,  that  on  the  ninth  day  of  February,  in  the  fifty-fifth 
year  of  the  independence  of  the  United  States  of  America,  A.D.  1831, 
John  Origg,  of  the  said  district,  has  deposited  in  this  office  the  title 
of  a  book,  the  right  whereof  he  claims  as  proprietor,  in  the  words 
following,  to  wit : 

An  Elementary  Treatise  on  Midwifery  :  or  Principles  of  Tokology 
and  Embryology.  By  Alf.  A.  L.  M.  Velpeau,  M.D.  &c.  &c.  Trans- 
lated from  the  French  by  Charles  D.  Meigs,  M.D.  Member  of  the 
American  Philosophical  Society;  Lecturer  on  Midwifery  and  the 
Diseases  of  Women  and  Children,  &c.  &c. 

In  conformity  to  the  act  of  the  congress  of  the  United  States,  enti- 
tled, "  an  act  for  the  encouragement  of  learning,  by  securing  the 
copies  of  maps,  charts  and  books  to  the  authors  and  proprietors  of  such 
copies  during  the  times  therein  mentioned  ;"  and  also  to  the  act,  en- 
titled, "an  act  supplementary  to  an  act,  entitled,  '  an  act  for  the  en- 
couragement of  learning,  by  securing  the  Copies  of  maps,  charts  and 
books  to  the  authors  and  proprietors  of  such  copies  during  the  times 
therein  mentioned,'  and  extending  the  benefits  thereof  to  the  arts  of 
designing,  engraving  and  etching  historical  and  other  prints." 
D.  CALDWELL, 
Clerk  of  the  Eastern  District  of  Pennsylvania. 


Phihdclphia : 

Printed  by  James  Kay,  Jun.  &  Co. 

Printen  to  the  Philadelphia  Medical  and  American  Philo«)phlcal  Socletie*. 

No.  4,  Minor  Street. 


TO 


THOMAS  C.  JAMES,  M.D. 

PROFESSOR    OF    MifiWIFERY    AND    THE    DISEASES    OF    WOMEN   AND 
CHILDREN  IN  THE  UNIVERSITY  OF  PENNSYLVANIA. 


Respected  Sir: 

I  take  the  liberty  of  addressing  the  following  work  to  you, 
not  only  for  the  purpose  of  showing  my  sense  of  your  high  rank 
and  authority  in  the  science  and  art  so  ably  treated  of  by  M. 
Velpeau,  but  also  as  a  testimonial  of  my  gratitude  for  many 
acts  of  kindness  received  at  your  hands. 

I  was  induced  to  undertake  the  preparation  of  it  for 
the  American  press,  by  a  sincere  desire  to  see  so  excel- 
lent a  book  in  the  hands  of  the  profession  in  this  country,  a 
book  which,  as  I  think,  cannot  be  read  without  exciting  in 
the  mind  sentiments  of  great  respect  for  the  science  of 
Tokology,  as  M.  Velpeau  denominates  it,  and  a  correspond- 
ing desire  to  see  it  advanced  in  all  the  relations  of  its  real  useful- 
ness and  dignity.  I  am  willing  to  admit  that  we  have,  already, 
a  good  book  in  the  American  edition  of  Baudelocque's  work, 
which,  however,  is  but  an  abridgement.  We  have  no  transla- 
tions of  the  works  of  Capuroo,  Maygrier,  Gardien,  Duges, 
Flamant,  or  those  admirable  writings  of  Mesdames  Lacha- 
pelle  and  Boivin.     It  did  not  seem  improper,  therefore,  to 


Jy  DEDICATION. 

add  to  our  stock  one  of  the  most  enlightened  and  recent  of 
the  French  authorities. 

M.  Velpeau  will  readily  be  admitted,  by  those  who  read 
this  volume,  to  be  a  man  of  talents  and  industry  of  a  high 
order;  an  admission,  confirmed  not  merely  by  reference  to  his 
writings,  but  also  by  the  sentiments  of  public  journalists  in 
his  own  country,  where  the  competition  among  men  of  letters 
is  so  great  and  stirring,  that  he  who  attains  to  distinction,  will 
be,  ipso  facto,  considered  as  having  deserved  it.  In  the  re- 
public of  letters  in  France  palmam  qui  meruit  Jerat,  may  he 
regarded  as  a  maxim  in  daily  use  and  practice. 

The  admirable  composition  of  Dr  Denman,  of  which  Pro- 
fessor Francis  has  lately  furnished  the  public  with  an  improved 
edition,  and  the  systems  of  Burns,  Ashwell,  and  Ryan,  cannot 
be  regarded  as  completely  filling  the  chasm  which  has  opened  in 
the  last  half  century  between  the  old  limits  of  the  science  and 
its  present  advanced-  station.  I  ought  not  in  this  enumera- 
tion to  omit  a  reference  to  the  work  of  Dr  Dewees,  which, 
rich  as  it  is  in  business  details,  and  valuable  for  the  soundness 
of  its  practical  precepts,  may,  nevertheless,  without  the  fear  of 
disparagement,  be  considered  less  full  and  complete  in  regard  to 
its  anatomical  and  physiological  features,  and  the  ample  collation 
of  good  authorities,  than  the  volume  which  I  have  the  honor 
to  present  to  you.  To  say  that  Dr  Dewees's  "  System  of  Mid- 
wifery" is  creditable  to  the  science  and  to  himself,  is  not 
enough,  where  it  is  universally  admitted  to  be  honourable  to 
the  country. 

Denman,  Burns,  Dewees  and  Velpeau,  will,  I  trust,  be  con- 
sidered as  a  collection  of  authorities,  at  the  least,  small  enough 
for  any  student  or  any  practitioner  of  the  delicate,  difficult 
and  responsible  art  of  Midwifery:  if  so,  I  shall  be  absolved 
from  the  charge  of  adding  to  the  number  of  authors,  one 
whose  works  are  useless  or  superfluous. 

In  relation  to  the  manner  in  which  I  have  executed  my 
humble  task,  nothing  ought  to  be  said  by  me,  further  than 
that  I  have  aimed  to  give  a  transcript  of  the  author's  perform- 


DEDICATION.  V 

ance,  and  not  to  substitute  one  of  my  own  under  his  name  and 
authority. 

There  are  some  slight  errors  which  I  shall  not  point  out, 
because  I  presume  every  reader  of  such  a  work  is  as  com- 
petent as  I  am  to  correct  them:  I  have  no  excuse  to  offer  to 
those  who  may  detect  them,  except  that  the  proofs  have  been 
read  with  much  attention,  and  a  desire  to  attain  a  great  degree 
of  correctness. 

You,  I  hope,  sir,  who  know  how  much  of  my  time  is  absorb- 
ed in  the  business  of  my  profession,  will  have  the  goodness  to 
overlook  all  such  minor  faults  of  the  translation  as  might  na- 
turally occur,  under  the  circumstances  in  which  I  am  placed, 
and  accept  it,  and   with  it  the  assurance  of  my  profound 

respect. 

CH.  D.  MEIGS. 
Jan.  28th,  1831. 


AUTHOR'S  PREFACE. 


Confounded  with  the  other  branches  of  medicine,  and  pur- 
sued almost  exclusively  by  mere  medicasters  during  a  long 
series  of  ages,  the  Art  of  Midwifery  has  advanced  with  ex- 
treme slowness.  Among  the  Egyptians,  the  Hebrews,  the 
Greeks,  and  the  Romans,  it  was  reduced  in  some  sort  to  what 
concerns  the  cutting  of  the  umbilical  cord;  and  even  at  the 
present  time^  in  countries  that  are  imperfectly  civilized,  those 
who  make  a  profession  of  it  inspire  so  little  confidence,  that 
the  husband  is  still  compelled  to  imitate  the  conduct  of  the 
first  man,  that  is  to  say,  he  becomes  the  accoucheur  of  his  wife. 
These  primitive  notions  have  doubtless  long  ceased  to  exist 
amongst  us;  in  our  day  the  Art  of  Midwifery  is  especially  seen 
to  acquire  a  rapid  movement,  and  to  progress  equally  with  the 
other  departments  of  the  art  of  curing;  it  would,  however, 
be  wrong  to  conclude  from  hence,  that  every  thing  has  been 
already  done,  and  that  no  further  improvements  can  be  made: 
the  Science  of  Obstetrics  ought  to  follow  the  movements  of  the 
age,  and  advance  if  it  would  not  retreat.  It  seems  to  me 
that  it  may  be  defined,  the  ensemble  of  knowledge  relative 
to  the  reproduction  of  the  human  species.  By  studying  it 
under  this  extensive  and  philosophic  view,  and  by  doing  away 
the  absurd  and  vulgar  prejudice,  that  it  is  impossible  to  be 
at  the  same  time  a  skilful  accoucheur  and  an  able  physician, 
we  shall  succeed  in  establishing  it  upon  a  basis  worthy  of 
the  subject! 

In  this  book  I  have  endeavoured  not  to  be  unjust  to  any 


Viil  PREFACE. 

one.  I  have  spoken  on  all  occasions  without  being  influenced 
by  hatred  or  prejudice,  and  I  may  add,  without  enthusiasm, 
and  with  absolute  independence.  The  sciences  compose  a  re- 
public in  which  every  man  is  at  liberty  to  make  researches, 
to  examine  and  think  for  himself,  as  well  as  to  say  what  he 
thinks.  Truth  is  the  avowed  object  of  all  who  cultivate 
them:  it  may  be  reached  by  a  hundred  diflferent  routes,  and 
I  never  could  understand  how  any  reasonable  man  could  be 
offended  because  his  ideas  fail  to  be  received  as  laws  for  other 
men. 

In  adopting  a  course  somewhat  different  from  that  pursued 
by  the  modern  classic  writers,  I  was  not  misled  as  to  its 
merits.  No  person  attaches  less  importance  to  classifications 
than  I  do,  or  is  more  fully  convinced  that  every  one  has  an 
equal  right  to  choose  for  himself.  The  course  I  have  chosen 
appeared  to  me  to  be  more  natural  than  any  other;  I  found 
that  one  was  necessary  for  my  purposes,  and  I  preferred  this 
one;  I  shall  therefore  make  no  further  attempt  to  justify  it; 
it  belongs  to  the  public  to  decide  whether  it  be  good  or  bad. 

I  have  given  a  name  to  the  science  of  the  accoucheur;  in 
the  first  place,  because  it  is  a  substitute  for  a  periphrasis;  and 
in  the  next,  because  it  is  quite  extraordinary  that  that  science 
should  have  remained  until  the  present  day  without  any 
special  qualification  in  France.  From  the  earliest  years  of 
my  studies,  I  employed  the  term  (obsieiricie)  obstetrics,  de- 
rived from  the  Latin  obstetriXf  midwife.  I  think  it  more  uni- 
form in  acceptation  than  the  word  obstetrique,  which  is  used 
in  Germany,  and  which  M.  Duges  has  desired  to  establish 
among  us.  But  the  word  tokology,  derived  from  rojt«c,  child- 
birth, and  from  xe>oc,  study,  out  of  which  may  be  constructed 
the  terms  tokological,  tokologist,  tokologue,  iokograph,  &c. 
and  which  present  nothing  hard  or  difficult  in  their  pronunci- 
ation, has  seemed  to  me  more  conformable  to  the  habits  of 
our  language  and  the  rules  of  grammar. 

It  is  of  the  nature  of  a  preface  to  set  forth  the  motives  of 
the  author  of  a  doctrinal  book,  and  the  advantages  which  he 


PREFACE.  ix 

supposes  himself  to  enjoy  over  his  predecessors.  I  hope  that 
I  may  be  permitted  to  dispense  with  this  common  form. 
Since  the  time  of  Baudelocque  very  good  treatises  on  mid- 
wifery have  been  composed;  I  am  the  first  to  proclaim  it,  and 
have  not  the  smallest  intention  to  contest  the  rights  which 
their  authors  may  have  acquired  to  the  enjoyment  of  the  pub- 
lic esteem.  But  at  the  present  day,  every  thing  proceeds 
with  such  rapidity,  that  each  moment  is,  so  to  speak,  marked 
by  new  wants.  Besides,  as  the  last  speaker,  I  might  hope  that 
I  could  produce  a  work,  if  not  better,  at  least  equally  useful 
with  others;  it  remains  to  be  seen  whether  I  have  succeeded. 

In  composing  it,  I  have  attempted  to  make  a  profitable  use, 
not  only  of  the  works  of  my  own  countrymen,  whether  an- 
cients or  contemporaries,  but  also  of  all  such  foreign  writers  as 
I  could  have  access  to.  Numerous  materials  have  also  been 
furnished  by  between  one  thousand  and  twelve  hundred  la- 
bours, examined  with  care  either  at  the  Maternite  at  Tours, 
and  the  hospital  Saint  Louis,  while  I  was  a  student  there,  or 
at  the  hospital  de,  Perfectionnement,  while  I  was  in  service 
there  as  chef  de  Clinique,  or  at  my  amphitheatre  and  in  my 
private  practice,  since  I  began  to  teach  tokology;  lastly,  I  have 
thought  it  best  to  embody  in  the  work  a  detailed  extract  of  a 
treatise  on  Embryology,  which  I  have  been  preparing  for  a 
long  time  past. 

I  may  be  permitted  to  make  an  appeal  to  my  brethren  upon 
this  subject.  If,  in  the  space  of  six  years,  I  have  been  enabled 
to  make  dissections  of  nearly  one  hundred  and  forty  products 
of  conception  within  the  third  month  of  gestation,  I  am  in- 
debted for  those  opportunities  to  the  kindness  of  a  great 
many  physicians  and  female  practitioners  of  midwifery.  I 
shall  testify  my  thankfulness  to  them  in  another  work,  but  in 
the  mean  time,  I  cannot  express  the  amount  of  obligations  they 
will  confer  by  continuing  to  send  me  such  specimens. 
B 


CONTENTS. 


CHAPTER  I. 

Of  the  Parts  that  are  concerned  in  Generation,  Pregnancy,  and  Labour,  17 

Of  the  Pelvis,              .......  n 

ARTICLE  T. 

SECTION  1. 

Of  the  Bones  of  the  Pelvis,      -           -           -           -           -           -  18 

§.  I.      Of  the  sacrum,      ..--..  18 

§.  II.    Of  the  coccyx,      -----.  19 

§.  III.  Of  the  coxal  bones,          _           ....  20 

SECTION  2. 

Of  the  Articulations  or  Symphyses  of  the  Pelvis,          •            •            -  21 

SECTION  8. 

Of  the  Pelvis  in  General,         ......  23 

§.  I.       External  surface,             .....  23 

§.  11.      Internal  surface,             .....  23 

§.  III.     Straits  of  the  pelvis,        .....  26 

§.  IV.    Dimensions  of  the  excavation,    -            -            -            -  27 

§.  V.      Base  of  the  pelvis,           -----  28 

§.  VI.    Dimensions  of  the  pelvis  unconnected  with  its  axes  or  straits,  29 
§.  VII.  Differences  of  the  pelvis  in  respect  to  ages.,  sexes,  and  species,    29 

§.  VIII.  Of  the  recent  pelvis,        .....  32 

§.  IX.    Uses  of  the  pelvis,           .....  33 

SECTION  4. 

Of  the  Deformed  Pelvis,          ......  34 

§.  I.      Deformity  from  excess  of  amplitude,         -            -            -  35 

§.  II.    Deformity  from  want  of  amplitude,           -            -            •  36 

§.  III.  Faulty  direction  of  the  axes,          -            -            -            -  40 

§.  IV.  Causes  of  deformities  of  the  pelvis,            -            -            -  40 

§.  V.     Of  the  mensuration  of  the  pelvis,              -            -            -  42 

ARTICLE  IL 

Of  the  Sexual  Organs,              ......  43 


CONTENTS. 


Of  the 

§• 
§. 
§. 
§. 
§• 
§• 
§• 
§• 
§• 


SECTION  1. 
External  Parts  of  Generation,    - 

I.  Of  the  mens  veneris, 

II.  Of  the  labia, 

III.  Of  the  lesser  labia, 

IV.  Of  the  clitoris, 

V.  Of  the  vestibule, 

VI.  Of  the  urethra, 

VII.  Of  the  hymen, 


VIII.  Of  the  myrtiforra  or  vaginal  caruncles, 

IX.  Of  the  perineum,  fossa  navicularis,  fourchette,  froeuum,  com- 
missure, ...... 

§.  X.       Differences  between  the  external  organs  of  geireration  in  wo- 
men and  those  of  brutes,      .... 
Anoraalyof  the  external  organs  of  generation. 


§.  XI 


Internal  Genital  Organs, 


SECTION  2 


§.  I.  Of  the  uterus,  - 
A.  External  surface, 
6.  Internal  surface, 

C.  Dimensions  of  the  womb, 

D.  Structure, 
§.  II.       Fallopian  tubes, 
§.  III.     Ovaries, 
§.  IV.     Ligaments  of  the  uterus, 
§.  V.       Of  the  vagina,    - 
§.  VI.      Of  the  sexual  organs  in  general, 
§.  VII.    Varieties  in  the  internal  organs  of  generation  in  animals 
§.  VIII.  Difference  according  to  ages, 
§.  IX.    Anomalies, 
§.  X.      Hermaphrodism, 


49 

49* 

49 

50 

51 

52 

53 

53 

54 

56 

56 
57 


58 
58 
58 
60 
61 
62 
67 
68 
69 
71 
73 
74 
76 
76 
80 


CHAPTER  II. 


Functions  of  the  Sexual  Organs, 


ARTICLE  I. 
or  Menstruation,  or  the  Catamenial  Discharge, 


82 


ARTICLE  II. 


Of  Reproduction, 


SECTION  1. 
Of  the  Generation  or  Procreation  of  Germs, 
§.  I.    Of  the  female  germ, 
§.  II.  Of  (he  male  germ, 


91 


94 
94 
95 


Of  Fecundation, 
Of  Conception, 


CONTENTS. 
SECTION  2. 
SECTION  3. 


xm 

98 
101 


CHAPTER  III. 


History  of  Gestation, 


Of  Trae  Pregnancy, 


ARTICLE  I. 


SECTION  1. 
Of  Uterine  Pregnancy,  .  .  -  - 

§.  I.      Local  phenomena,  ... 

§.  II.  Sympathetic  phenomena  and  rational  signs, 
§.  III.  Sensible  signs,  .... 
§.  IV.  Of  touching,  .... 

§.  V.  Ofballottement,  .... 
§.  VI.  Of  auscultation,     ...  - 

SECTION  2. 
Of  Extra-uterine  Pregnancy,    .  -  -  -  • 

§.  I.  Of  ovarian  pregnancy,         -  -  -  . 

§.  II.    Of  abdominal  pregnancy, 
§.  III.  Of  tubal  pregnancy,  ... 

§.  IV.  Of  interstitial  pregnancy, 
§.  V.    Causes  of  extra-uterine  pregnancy, 
§.  VI.   Signs  and  terminations  of  preternatural  pregnancy, 


ARTICLE  II. 


Of  False  Pregnancy, 


102 


103 


103 
103 
115 
120 
120 
123 
127 


1 82 
132 
133 
134 
135 
136 
137 


142 


ARTICLE  III. 

Of  Pregnancy  as  it  regards  the  sex  of  the  Foetus,        ...  144 

§.  I.     Is  it  possible  to  ascertain  the  sex  of  the  foetus  during  preg- 
nancy?  -...--.  144 
§•  II.    Is  it  possible  to  procreate  either  sex  at  pleasure?                -  147 
§.  III.  Of  the  influence  of  the  seasons  and  of  public  prosperity  upon 
9  the  production  of  the  sexes  and  the  proportion  of  concep- 
tions,      .......  149 


XIV 


CONTENTS, 


CHAPTER  IV. 


or  the  Human  Ovum, 


160 


ARTICLE  I. 

Of  the  Appendages  of  the  Foetus, 

SECTION  1. 

Of  the  Membranes,      ...  - 

§.  I.      Of  the  caduca  or  connecting  membrane, 
§.  II.    Of  the  proper  membranes  of  the  ovum, 

A.  Of  the  chorion, 

B.  Of  the  amnios, 

§.  III.  Of  the  water  of  the  amnios, 

SECTION  2. 
Of  the  Vesicles  of  the  Embryo, 
§.  I.    Of  the  umbilical  vesicle, 
§.  II.  or  the  allantois. 


SECTION  S. 


Of  the  Cord  and  Placenta, 

§.  I.    Of  the  umbilical  cord, 
§.  II.  Of  the  placenta,     - 


150 


. 

. 

160 

. 

. 

150 

. 

. 

167 

. 

. 

157 

. 

. 

161 

.  / 

- 

163 

166 

. 

. 

166 

- 

- 

171 

. 

175 

- 

. 

175 

. 

- 

179 

ARTICLE  II. 


Of  the  Foetus, 


SECTION  1. 
Development  of  the  Embryo  and  of  the  Foetus, 

§.  I.      Of  the  embryo  in  general,  .... 

§.  II.    Of  the  head  and  organs  of  the  senses, 

^.  III.  Of  (he  members  and  lower  parts  of  the  trunk, 

§.  IV.  Of  the  foetal  head  at  term,  .... 

§.  V.    Of  the  attitude  and  position  of  the  foetus  during  pregnancy, 

§.  VI.  Of  superfoetation,  ..... 

SECTION  2. 
Functions  of  the  Foetus,  .-.--- 

§.  I.      Of  the  nourishment  of  the  foetus, 

^.  II.    Circulation  of  the  foetus,  .... 

%.  III.  Of  the  respiration  of  the  foetus,    -  -  -        •  - 

%.  IV.  Of  the  viabilily  of  the  foetus,         .  .  -  - 


188 


188 
190 
192 
194 
201 
206 
208 


212 
212 

220 
224 
226 


ARTICLE  III. 
or  Abnormal  Expulsions  of  the  Human  Ovum, 


229 


CONTENTS.  XV 

SECTION  1. 
Of  Abortion,     --.-....  229 

SECTION  2. 
Of  the  Term  of  Gestation  and  of  Retarded  Births,        -  •  -  244 

SECTION  3. 
Of  Precocious  or  Early  Births,  .....  247 


CHAPTER  V. 

Of  Labour,       --......  248 

ARTICLE  I. 

Of  Labour  in  General,             ......  261 

SECTION  1. 

Of  the  Causes  of  Labour,        -.-...  252 

§.  I.    Efficient  causes,     ......  £62 

§.  II.  Determining  or  occasional  causes,              ...  258 

SECTION  2. 

Of  Labour,      --•-....  262 

§.  I.       Precursory  or  preliminary  symptoms  of  labour,                 -  263 

§.  II.      First  stage,  or  period  of  dilatation,           .            .            -  266 

§,  III.    Second  stage,  or  period  of  expulsion,       -            -            -  266 

§.  IV.     Qf  labour-pains,               .....  270 

§.  V.      Of  the  dilatalion  of  the  os  uteri,               •            .            -  275 

§.  VI.    Of  the  discharge  of  glairy  mucus,    -        .            -            .  278 

§.  VII.  Of  the  bag  of  waters,      .....  £80 

ARTICLE  II. 

Of  Eutocia  or  Simple  Labour,              .....  282 

SECTION  1. 

Of  Natural  Eutocia,                  ......  287 

§.  I.  Presentation  of  the  vertex,               ....  288 

First,  or  occipito-auterior  position,        .....  290 

A.  First  variety. 

Left  occipito-acetabular  position,         .....  291 

B.  Second  variety. 

Right  occipito-acetabular  position,        -            -            .            .            .  294 

C.  Third  variety. 

Occipito- pubic  position,            ---...  297 

Second,  or  occipito-posterior  position,              ....  299 

A.  First  variety. 

Left  fironto-acetabular  position,             -            .            .            .            .  300 


804 
807 
310 
311 
811 


xyj  CONTENTS. 

B.  Second  variety. 

Right  fronto-acetabular  position,  -  ,  -  -  -  -  302 

C.  Third  variety. 
Fronto-pubic  position.  ..... 

§.  II.  Presentation  of  the  face,     .  -  -  - 

A.  Right  inento-iliac  position,  -  -  - 

B.  Left  mento-illac  position, 

C.  Mento-sacral  position.     .... 

SECTION  2. 
Of  Unnatural  Eutocia,   ---.---  812 

§.  I.  Presentation  of  the  feet,        .....  817 

First ;  Calcaneo-anterior  position,         .....  318 

A.  First  variety. 

Loins  in  front  and  towards  the  left,       .....  318 

B.  Second  variety. 

Loins  in  front  and  towards  the  right,      -  ...  -  320 

C.  Third  variety. 

Loins  directly  in  front,  -     •       -  -  -  -  -  820 

Second  ;  Calcaneo-posterior  position,    -----  322 

Presentation  of  the  knees,  -  ...  -  326 

Presentation  of  the  breech,       ......  326 

SECTION  3. 

Of  the  Conduct  of  the  Accoucheur  during  Labour,       -  -  -  828 

§.  I.      Of  the  diagnosis,    -  -  -  -  -  -  829 

§.  II.    To  determine  the  position,  •  •  .        ,-  -  882 

§.  III.  Of  the  prognosis,  .....  886 

§.  IV.  Of  the  attentions  oecessary  for  the  woman  in  labour,        -  886 

ARTICLE  III. 

Of  Dystocia,      ....  .  -  -  863 

SECTION  1. 

Accidental  Dystocia,     -------  364 

§.  I.        Of  hemorrhagic  dystocia,  ....  864 

§.  11.       Of  convulsive  dystocia,   -  ...  -  881 

§.  III.     Dystocia  caused  by  premature  descent  of  the  umbilical  cord,  390 
§.  IV.     Dystocia  from  excessive  length  or  shortness  of  the  umbilical 

cord,  ......  893 

§.  V.       Aneurismal  dystocia,        .....  896 

§ .  y I.      Dystocia  from  asthma,  hydrothoraxi  gibbosity,  dropsy,  -  396 

§.  VII.    Hernial  dystocia,  -  -  -  -  -  396 

§.  VIIL  Dystocia  from  syncope,  ....  S96 

SECTION  2. 

EsMUlial  Dystocia,        ...-.-.  898 

§.  I.    Dystocia  occasioned  by  the  state  of  the  female  organs,  898 

^.11.  Dystocia  depending  on  the  foetus,    -  -  -  -  406 

SECTION  8. 
Dystocia  from  Wrong  Presentations  of  the  Foetus,  -  •  412 


CONTENTS. 


XVll 


§.  I.      Deviated  positions  of  the  head,     ....  413 

§.  II.     Deviated  breech  positions,  ....  413 

§.  III.  Deviated  positions  of  the  trunk  of  the  body,  -  .  414 


CHAPTER  VI. 

Obstetric  Operations,    ...                       ...  421 

ARTICLE  I. 

Of  Turning,      --......  4^1 

SECTION  1. 

Of  Turning  in  General,              -.-...  422 

SECTION  2. 

Of  Version  by  the  Head,           ......  428 

SECTION  3. 

Of  Turning  by  the  Feet  or  Pelvis,        .....  430 

§ .  I.    Of  bringing  down  the  feet  when  the  head  is  at  the  orifice,  435 

A.  Left  occipito-iliac  position,        ....  435 

B.  Right  occipito-iliac  position,      ....  442 
§.  II.  Of  turning  by  the  feet  in  presentations  of  the  trunk,           .  443 

A.  Positions  of  the  shoulder  and  side,  .  -  .  444 
First ;  positions  of  the  left  shoulder,  .....  445 
Second  ;  positions  of  the  right  shoulder,           ....  447 

B.  Presentation  of  the  sternum,      ....  443 

C.  Presentation  of  the  back,           ....  449 

SECTION  4. 

Of  the  Maneuvre  in  Presentations  of  the  Pelvis,            -            -            -  450 

A.  Positions  of  the  feet,      .....  459 

B.  Positions  of  the  breech,              -             -            .            .  452 

SECTION  5. 

Presentation  of  the  Arm,            ---...  455 

General  Recapitulation  on  the  Maneuvre,          -             .             .             .  459 

ARTICLE  n. 

Of  the  Forceps,             ---.-..  459 

SECTION  1. 

The  Forceps  in  itself  considered,          ..'...  459 

SECTION  2. 

Of  the  Use  of  the  Forceps,        -            .            .           .            .            .  452 

§.  I.        Oceipito-anterior  position,           .....  467 

§.  II.      Occipito  posterior  position,          ....  471 

§.  III.     Left  occipito-iliac  position,         ....  471 


xviii  CONTENTS. 

§ .  IV.      Right  occipito-iliac  position,      .  -  -  -  472 

§ .  V.       Positions  of  the  pelvis,  ....  472 

§.  VI.      The  child  is  completely  or  partially  double,        -  -  474 

§.  VII.    The  head  separated  from  the  body  remains  alone  in  the  pelvis,  474 

§.  VIII.  Recapitulation  on  the  employment  of  the  forceps,  -  475 

ARTICLE  III. 

Of  the  Lever,  .......  477 

SECTION  1. 
Of  the  Lever  in  itself  considered,        .....         477 

SECTION  2. 

Use  of  the  Lever,        -  -  -  -  -  -  -  478 

§.  I.       Use  of  the  lever  as  a  crotchet,     ....  479 

§  II.       Of  the  lever  used  as  a  lever,        ....  480 

ARTICLE  IV. 
Of  the  Fillet, -  481 

ARTICLE  V. 

Of  the  Locked  Head,  ......  482 

ARTICLE  VI. 

Of  the  Measures  rendered  necessary  by  Narrowness  of  the  Pelvis,      -  487 

SECTION  1. 
Of  Regimen  as  a  means  of  enabling   Women  vtrith  Contacted  Pelvis  to 

be  delivered  vrithout  the  assistance  of  any  surgical  operation,   -  489 

SECTION  2. 
Of  Abolition  brought  on  for  the  purpose  of  rendering  Symphyseotomy  or 

the  Cesarean  Operation  unnecessary,     ....  490 

SECTIONS. 
Of  Synpbyseotomy,  ......  497 

SECTION  4. 
Of  the  Cesarean  Operation,  &c.  .....  606 

SECTION  5. 
Vaginal  Cesarean  Operation,    ..•---  620 

SECTION  6, 
Of  Cepbalotomy  and  Embryotomy,      .  .  -  •  -  621 

SECTION  7. 
Of  CrotcbeU  and  their  Use,     -.-•.-  624 

SECTION  8. 
Of  the  Extraction  of  the  Bead  when  it  has  been  left  alone  in  the  Genital 

Passages,  ......  628 


CONTENTS.  xix 

CHAPTER  VII. 

Of  the  Natural  Phenomena  which  follow  the  Delivery  of  the  Foetus,  530 

ARTICLE  I. 

Of  the  Delivery  of  the  After-birth,       -----         530 

SECTION  1. 
Of  Simple  or  Natural  Delivery  of  the  After-birth,        -  -  -  530 

SECTION  2. 
Of  Complicated  Delivery  of  the  After-birth,    -  -  -  537 

ARTICLE  If. 

Management  of  the  Child,        -  -  -  -  -  552 

SECTION  1. 
Of  the  Foetus  in  a  Healthy  State,         -----  552 

SECTION  2. 

§.  I.      Of  tying  and  cutting  the  cord,       -  -            -  -  553 

§.  II.    Of  cleansing  the  child,                   -  .  .  557 

§.  III.  Of  dressing  the  child,        -            -  "     -            .  -  559 

SECTION  3. 

Of  the  Foetus  in  a  State  of  Disease,     -----  561 

§.  I.     Of  asphyxia,  ------  661 

§ .  II.    Of  the  apoplectic  state,     -  -  -  -  .  5^5 

§.  III.  Of  some  other  states  of  the  new  born  child,  -  -  567 

ARTICLE  III. 

Management  of  the  Lying-in  Woman,  -  -  -  -         569 


AN  ELEMENTARY 


TREATISE    ON    MIDWIFERY 


CHAPTER  I. 

Of  the  Parts  that  are  concerned  in  Generation,  Preg- 
nancy, and  Labour. 


ARTICLE  I. 

'Of  the  Pelvis. 

1.  The  pelvis,  a  sort  of  bony  girdle  or  cavity,  which  constitutes 
the  inferior  termination  of  the  trunk  of  the  body,  is  found,  in  the 
human  species,  between  the  spine,  which  it  supports  posteriorly^ 
and  the  thigh  bones,  on  which  it  rests  anteriorly.  Its  shape,  which 
is  very  irregular  and  difficult  to  describe,  resembles  in  some  mea- 
sure that  of  a  cone  with  its  apex  and  base  strongly  inclined  towards 
each  other,  on  their  anterior  face.  Regarding  it  as  an  appendage 
both  of  the  vertebral  column  and  of  the  inferior  extremities,  the  ana- 
tomists who  lived  antecedently  to  the  time  of  Vesalius,  gave  no  par- 
ticular description  of  it.  Diemerbroeck,  Dionis,  Saint  Hilaire,  Mau- 
riceau,  and  De  La  Mottc  scarcely  dwell  for  a  moment  upon  it  in 
their  works  :  and  even  at  the  present  day,  the  learned  who  aim  to 
promote  the  honour  of  what  is  called  phibsophical  anatomy,  have, 
for  the  major  part,  returned  in  this  respect  to  the  same  way  of  think- 
ing as  the  ancient  naturalists.  But  although  the  development  of 
the  skeleton  might,  in  a  system  of  general  zoology,  permit  us  to  take 
C 


18 


OF  THE  PELVIS. 


such  a  view  of  it,  it  does  not  follow  that  we  ought  to  do  so  in  toko- 
logy. The  accoucheur  must  necessarily  study  the  pelvis  as  a  por- 
tion distinct  from,  and,  as  far  as  connected  with  his  art,  independent 
of  the  rest  of  the  body.  Hence  it  is,  that  all  authors  since  the  time 
of  Smeliie  and  Levret  have  followed  this  course;  which  I  shall  ac- 
cordingly adopt. 

SECTION  1. 
Of  the  Bones  of  the  Pelvis. 

2.  There  are  four  bones  in  the  adult  pelvis  :  the  sacrum  and  coc- 
cyx posteriorly,  and  on  the  median  line;  and  the  coxal  bones  in  front, 
and  on  the  sides.  As  he  who  is  destined  to  engage  in  the  practice 
of  midwifery  ought  to  be  made  acquainted  with  the  entire  pelvis,  I 
do  not  deem  it  necessary  to  dwell  at  length  upon  the  graphic  details 
that  are  to  be  found  in  most  of  the  classical  works  upon  each  con- 
stituent portion  of  it.  On  this  subject  there  exists,  even  in  our  most 
modern  works,  quite  a  faulty  mode  of  exposition,  which  it  is  proper 
to  reform  :  after  the  manner  of  Baudelocque,  the  pubis,  the  ilium 
and  ischium  are  minutely  described  as  so  many  separate  bones, 
while,  for  the  most  part,  the  coxal  bone  is  almost  entirely  lost  sight 
of;  and  yet  it  alone  possesses  any  considerable  interest  in  relation 
to  midwifery,  inasmuch  as  the  throe  pieces  of  which  it  is  composed 
are  united  into  one  before  the  individual  is  liable  to  becpme  preg- 
nant. 

§.  I.  Of  the  sacrum  (o,?  .sacrum.,  ,t.  diininm'). 

3.  The  sacrum,  a  single  bone,  situated  between  the  last  lumbar 
vertebra  and  the  coccyx,  is  locked  in,  as  it  were,  between  the  two 
ossa  ilia. 

4.  Of  a  triangular  or  pyramidal  shape,  curved  forwards  on  its  an- 
terior surface,  it  presents  to  the  examiner,  sncccssively,  an  internal 
or  pelvic  region,  and  external  or  posterior  retjion,  two  edges,  .n  base 
and  an  apex. 

5.  Its  anfmor  .'?«ir/aro,  .somewhat  concave,  j)resenls,  1.  Along  its 
middle,  four  or  five  quadrangular  facclles,  and  the  .same  number  of 
transverse  lines;  2.  Outwardly,  the  five  anterior  sacral  holes,  ter- 
minating in  an  cijual  number  of  converging  grooves,  for  the  pas.sage 
of  the  anterior  branches  of  the  sacral  nerves;  .3.  More  outwardly 
still,  and  between  these  openings,  certain  rough,  uneven  surfaces, 
for  the  attachment  of  the  pyramidal  mu.scles. 

fi.    Its  pwttnor  nurfacc,  which  is  convex  and  very  uneven,  exhi 


OF  THE  PELVIS.  19 

bits,  along  its  middle,  a  series  of  protuberances  which,  by  their  union, 
constitute  the  crista  of  the  sacrum;  above  this  crest  is  seen  the  open- 
ing of  the  sacral  canal;  below  are  the  two  branches  formed  by  its 
bifurcation,  the  triangular  space  which  terminates  the  spinal  canal, 
and  the  tubercles  or  points  called  the  horns  of  the  sacrum.  On 
either  side  of  the  false  vertebral  spines,  are  seen  the  sacral  grooves, 
the  posterior  sacral  holes,  and  still  nearer  to  the  edges  of  the  bone 
are  to  be  found  certain  rough  surfaces  that  serve  for  the  attachment 
of  the  posterior  sacro-iliac  ligaments. 

7.  Its  edges  may  be  divided  into  two  portions :  one,  superior, 
very  thick,  exhibits,  on  its  anterior  half,  a  semilunar  articular  facette 
which  unites  it  to  the  coxal  bone;  on  its  posterior  half,  a  hollow,  and 
certain  rough  protuberances  for  the  attachment  of  the  sacro-iliac 
ligaments;  the  other,  inferior,  thin,  almost  sharp,  serves  for  the  in- 
sertion of  the  sacro-sciatic  ligaments. 

8.  Its  hasei  very  broad,  looks  upwards.  On  its  middle  may  be 
seen  a  plain  elliptical  surface,  situated  transversely,  inclined  more  or 
less  backwards,  and  which  is  articulated  with  the  last  lumbar  verte- 
bra; outwards,  and  a  little  forwards,  a  triangular  surface,  the  lesser 
wing  of  the  sacrum^  which  is  slightly  depressed  towards  its  anterior 
face,  and  concurs  in  forming  the  internal  iliac  fossa;  lastly,  we  ob- 
serve on  the  posterior  surface,  the  opening  of  the  sacral  canal,  and 
the  two  articular  apophyses  of  the  first  piece  of  the  sacrum. 

9.  Its  apex^  thin,  elliptical,  slightly  convex,  is  received  into  the 
base  of  the  coccyx. 

10.  The  sacrum,  a  simple  prolongation  of  the  spine,  is  formed  by 
the  union  of  five  vertebra?.  Near  forty  points  of  ossification  maybe 
observed  in  it;  at  birth  it  is  still  formed  of  fifteen  pieces,  three  for 
each  vertebra;  but  soon  afterwards  it  only  exhibits  five,  which,  also, 
always  coalesce  before  the  age  of  puberty, 

§.  II.  Of  the  coccyx  (^ossa  coccygis), 

11.  The  coccyx  is  a  sort  of  rudimental  sacrum,  whose  anterior 
face,  almost  plane,  supports  the  end  of  the  rectum,  while  its  pos- 
terior surface,  slightly  convex,  is  only  separated  from  the  skin  by 
the  posterior  sacro-coccygeal  ligament.  Its  edges  serve  as  points 
of  attachment  for  the  small  sciatic  ligament,  and  ischio-coccygeus 
muscle;  its  base,  somewhat  concave,  surmounted  laterally  by  two 
prolongations  resembling  horns,  is  articulated  with  the  apex  and  cor- 
nua  of  the  sacrum.  Its  apex,  tubercular  and  rounded,  gives  inser- 
tion to  the  external  sphincter  of  the  anus. 

12.  The  three  or  four  pieces  of  which  it  is  composed,  mere  ves- 
tiges of  an  equal  number  of  vertebral  bodies,  remain  for  a  long 


20  OF  THE  PELVIS. 

while  movable  upon  each  other;  however,  they  at  length  coalesce; 
but,  in  most  women,  the  bone,  as  a  whole,  loses  its  power  of  moving 
upon  the  sacrum  only  at  a  very  advanced  age. 

§.  III.  Of  the  coxal  bone  {os  eoxalium). 

13.  The  bone  of  the  ilium,  the  hip  bone,  the  nameless  bone,  or 
more  properly,  as  was  long  ago  indicated  by  Celsus,  the  coxal  bone, 
situated  between  the  femur  and  the  sacrum,  alone  forms  the  two  an- 
terior and  lateral  thirds  of  the  pelvis. 

14.  Of  an  irregular  quadrangular  shape,  looking  as  if  strangula- 
ted at  its  middle,  and  twisted  in  two  opposite  directions,  the  coxal 
bone  exhibits  two  surfaces  and  four  edges. 

15.  On  its  internal  or  pelvic  surface,  which  is  divided  into  two 
nearly  equal  portions,  we  distinguish,  above,  a  large  excavation 
called  the  internal  iliac  fossa,  which  is  filled  by  a  muscle  of  the  same 
name;  behind,  an  articular  surface,  of  a  semilunar  shape,  called  the 
articular  facette;  still  farther  behind,  certain  rugosities,  similar  to 
those  observed  on  the  edge  of  the  sacrum,  with  which  they  unite. 

On  its  inferior  half,  and  posteriorly,  is  seen  a  plane,  almost  trian- 
gular surface,  which  corresponds  to  the  cotyloid  cavity,  and  to  the 
body  of  the  ischium;  in  its  middle,  the  sub-pubal  opening;  in  front, 
the  internal  face  of  the  pubis,  and  of  the  ischio-pubal  ramus. 

16.  A  semicircular  edge,  thick,  smooth,  and  rounded  posteriorly, 
thin  and  sharper  in  front  where  it  terminates  in  the  crista  of  the 
pubis,  an  edge  which  forms  the  greatest  part  of  the  superior  strait, 
and  unites  these  two  halves  of  the  pelvic  surface  of  the  coxal  bone. 

17.  Its  external  or  femoral  surface  exhibits,  on  its  upper  half,  what 
IS  called  the  external  iliac  fossa,  filled  by  the  three  glutei  muscles; 
below,  the  sub-pubal  hole,  the  external  face  of  the  ischium  and  ischio- 
pubic  ramus;  in  the  middle,  the  cotyloid  cavity. 

1 8.  Its  upper  edge,  or  the  iliac  crista,  thicker  both  posteriorly  and 
anteriorly  than  in  the  middle,  twisted  like  an  italic  *,  divided  by  the 
anatomists  into  an  external  lip,  an  internal  hp,  and  an  interstice,  for 
more  conveniently  describing  the  attachment  of  muscles,  terminates 
in  front,  by  the  antero-superior  spine  of  the  ilium,  and  behind,  by 
the  postero-superior  spine  of  the  ilium. 

19.  halovjcr  edge  presents  three  portions  :  superiorly,  an  oval 
surface  for  the  articulation  of  the  pubes;  inferiorly,  the  tuberosity  of 
the  ischium;  and  in  the  middle,  the  edge  of  the  ischio-pubic  ramus, 
turned  somewhat  outwards. 

20.  On  its  anterior  edge,  j)roceeding  from  above,  downwards, 
and  from  the  ilium  towards  the  pubis,  we  remark  the  superior  iliac 
spine;  a  small  semilunar  notch;  the  inferior  iliac  spine;  the  groove 


OF  THE  PELVIS.  21 

for  tlie  psoas  and  iliac  muscles;  the  ileo-pectineal  eminence,  for  the 
insertion  of  the  lesser  psoas;  a  triangular  surface,  smooth,  inclined 
forwards,  and  concealed  by  the  pectinalis  muscle;  the  crest;  then 
the  spine  of  the  pubis;  and,  lastly,  the  angle  of  the  pubis. 

21.  On  its  posterior  edge,  in  proceeding  from  above  downwards, 
is  seen  the  posterior  superior  spine  of  the  ilium;  a  small  irregular 
notch  ;  the  postero-inferior  spine  of  the  ilium,  which  articulates 
with  the  sacrum;  the  great  ischiatic  notch;  the  ischiatic  spine;  the 
small  ischiatic  notch,  and  the  most  posterior  portion  of  the  tubero- 
'sity  of  the  ischium. 

22.  At  birth,  the  coxal  bone  is  composed  of  three  distinct  pieces: 
one  superior,  the  ilium.,  which  constitutes  the  hip  and  the  two  iliac 
fossa;  one  inferior,  the  ischium,  which  supports  the  weight  of  the 
body  when  seated;  the  third,  anterior,  the  pubis,  to  which  are  ap- 
pended, as  it  were,  the  organs  of  generation.  It  is  in  the  cotyloid 
cavity,  at  the  ileo-pectineal  eminence,  and 'in  the  middle  of  the 
ischio-pubal  ramus,  that  these  three  bones  at  length  are  blended  into 
one  about  the  period  of  puberty;  but  there  are  commonly  added  in 
childhood,  a  plate  for  the  crest  of  the  ilium,  one  for  the  tuberosity  of 
the  ischium,  another  point  of  ossification  for  the  antero-inferior  spine, 
and  a  fourth  for  the  spine  of  the  pubis;  which  sometimes  do  not 
coalesce  with  the  principal  pieces  until  a  very  late  period. 


SECTION  2. 
Of  the  Articulations,  or  Symphyses  of  the  Pelvis. 

23.  There  are  three  principal  articulations  of  the  pelvis:  one  for 
the  two  pubes  in  front,  and  two  for  the  bones  of  the  ilium  and  the 
sacrum  behind. 

24.  At  the  anterior  or  median  symphysis,  the  bones  are  kept  in 
contact  by  a  fibro-cartilaginous  substance  called  the  interpubal  liga- 
ment, and  whose  thickness  is  far  from  being  uniform  at  every  point 
of  the  kind  of  ring  or  oval  circle  which  it  represents.  Its  thickness, 
which  is  very  considerable  on  the  upper  part,  a  little  less  so  in  front, 
and  much  less  so  behind,  becomes  suddenly  much  greater  below, 
where  the  fibrous  body  assumes  the  name  of  sub-pubal  or  triangular 
ligament.  In  the  centre,  the  articular  surfaces  are  separated  by  a 
very  thin'  plate  of  cartilage,  which  in  early  life,  and  even  in  a  good 
many  adult  women,  is  moistened  by  a  small  quantity  of  synovial 
fluid. 

A  portion  of  the  periosteum  lines  the  posterior  surface,  a  fibrous 
lamina  of  the  same  material  is  observed  in  front,  and  these  two  layers 


^3  OF  TPIE  PELVIS. 

have  received  the  names  of  anterior  and  posterior  ligaments  of  the 
symphysis  pubis. 

26.  The  sacro-iliac  or  posterior  symphyses  are  much  more  com- 
plex than  the  preceding.  There  the  sacrum  is  locked,  like  a  double 
wedge,  between  the  coxal  bones,  so  that  it  offers  a  very  efficient  re- 
sistance to  the  weight  of  the  body,  which  presses  it  from  above  down- 
wards, and  to  the  efforts  of  the  pelvic  viscera,  which  tend  to  force 
it  backwards;  its  articular  surfaces,  although  uneven,  are  nevertheless 
covered  with  a  very  thick  diarthrodial  cartilage,  while  those  of  the 
iliac  bones  are  wholly  destitute  of  them. 

26.  The  name  of  posterior  sacro-iliac  ligament  is  given  to  a  col- 
lection of  fibrous  bundles,  that  are  yellow,  elastic,  mixed  with  small 
lumps  of  fat  which  fill  up  the  uneven  and  rugous  excavation  that  is 
seen  behind  the  cartilaginous  surfaces.  These  fibrous  bundles,  of 
the  same  nature  with  the  yellow  ligaments  of  the  vertebra;,  are  com- 
posed of  fibres  decusssfting  in  every  direction,  and  are  united  almost 
intimately  with  the  sacrum  and  coxal  bones.  Being  of  considerable 
strengtij,  they  give  an  extraordinary  solidity  to  the  articulation  which 
they  concur  in  forming.  There  is  not,  rigorously  speaking,  any  an- 
terior sacro-iliac  ligament:  a  simple  lamella  of  the  pelvic  periosteum 
serves  in  its  stead. 

27.  Other  small  fibrous  bands  also  serve,  but  less  immediately, 
to  unite  the  bones  of  the  pelvis  behind.  These  are  the  sacro-sciatic, 
and  sacro-spinal  ligaments;  which,  by  passing  from  the  posterior 
spines  of  the  ilium,  and  from  the  inferior  half  of  the  edge  of  the  sa- 
crum to  the  spine,  and  tuberosity  of  the  ischium,  convert  the  two 
ischiatic  notches  into  holes. 

28.  The  connexions  of  the  pelvis  with  the  vertebral  column  and 
with  the  coccyx,  arc  efiectcd  by  two  amphiarthroses. 

20.  One,  the  sacro-coccygeal  articulation^  is  composed,  1.  Of  an 
elliptical  fibro-cartilaginous  lamina,  which  unites  the  point  of  the  sa- 
crum to  the  base  of  the  coccyx;  2.  Of  the  posterior  sacro-coccygeal 
ligament,  a  sort  of  prolongation  or  extension  of  the  supra-spinal 
ligament  of  the  vertebra?,  which  closes  the  lower  extremity  of  the 
sacral  canal;  and  3.  Of  the  anterior  sacro-coccygeal  ligament, 
formed  of  two  lateral  bands  united  at  their  point  on  the  front  of  the 
.second  or  third  piece  of  the  coccyx.  Naturally  very  movable  in 
women,  this  articulation  permits  the  coccyx  to  turn  backwards,  from 
half  an  incli  to  ;in  inch,  while  the  child  is  passing  through  the  lower 
strait. 

.30.  'I'iic  oilier,  ilic  .sacro-vcrtebral  articulation,  differs  from  the 
vertebral  amphiarthroses,  only  in  the  thickness  of  its  fibro-cartilage; 
in  the  obliquity  of  the  articular  faces  of  tlie  last  lumbar  vertebra,  and 


OF  THE  PELVIS. ,  23 

of  the  sacrum,  an  obliquity  which  produces  the  sacro-vertebral  angle, 
or  the  promontory ;  and  by  the  presence  of  tlie  ilio-lumbar  ligament, 
which  extends  from  the  last  transverse  vertebral  apophysis  to  the 
posterior  extremity,  and  not  to  the  posterior  spine  of  the  iliac  crest, 
as  is  incorrectly  asserted  by  several  modern  authors. 

31.  The  obturator  membrane,  and  the  ligament  of  Fallopius, 
which  extends  from  the  anterior  superior  spine  of  the  ilium  to  the 
spine  of  the  pubis,  constituting  the  crural  arch,  and  separating,  be- 
fore it  terminates,  into  two  columns  to  form  the  inguinal  ring,  com- 
pletes the  ligamentous  apparatus  of  the  pelvis. 

SECTION  3. 
Of  the  Pelvis  in  general. 

§.  I.  External  surface. 

32.  The  principal  use  of  the  external  surface  of  the  pelvis,  which 
is  very  uneven,  is  to  give  attachment  to  the  muscles  which  surround 
the  coxo-femoral  articulation;  it  may  be  divided  into  four  regions. 

33.  The  first,  anterior.,  bounded  on  the  sides  by  the  cotyloid  ca- 
vities, presents,  in  its  middle,  the  front  of  the  symphysis  of  the  pubis, 
and  laterally,  the  external  obturator  fossa,  filled  with  the  correspond- 
ing muscle. 

34.  The  second,  posterior .^  bounded  by  the  projection  of  the  coxal 
bones,  is  formed  almost  wholly  by  the  posterior  surfaces  of  the  sa- 
crum and  coccyx.  Consequently,  wc  may  observe  in  this  region 
the  sacral  crista  and  the  lower  orifice  of  the  spinal  canal;  the  sacral 
portion  of  the  vertebral  grooves  filled  with  the  point  of  the  sacro-spi- 
nal  muscle,  and  in  the  bottom  of  which  are  seen  the  ten  posterior 
sacral  holes,  from  whence  pass  the  nerves  of  the  same  name. 

35.  The  two  last,  lateral.,  enclosed  by  the  preceding,  present  the 
external  iliac  fossas  above;  below  and  behind,  the  posterior  surface 
of  the  sacro-ischiatic  ligaments,  and  the  plane  of  the  notches  or 
holes  of  the  same  name;  below  and  forwrirds.  the  cotyloid  cavity 
which  receives  the  head  of  the  femur. 

§.  II.  Internal  surface. 

36.  The  ancient  authors  have  compared  the  pelvis  to  a  barber's 
basin.  Although  trivial,  this  comparison,  nevertheless,  gives  a  pretty 
exact  idea  of  it.  We  may,  with  the  moderns,  divide  its  inner  face 
into  two  parts:  one,  superior.,  which  bears  the  name  of  greater  ba- 
sin, upper  basin,  or  abdominal  basin,  on  account  of  its  dimensions, 
its  situation,  or  the  parts  it  encloses;  the  other,  inferior,  and  which 
is  also  known  as  the  les.s-er  ba,nn.  or  the  pehnc  excavation . 


24  OF  THE  PELVIS. 

37.  The  abdominal  basin  constitutes  part  of  the  belly.  Of  an 
elliptical  form,  largely  notched  in  front,  where  it  corresponds  to  the 
hypogastrium,  notched  also  behind,  in  order  to  receive  the  lower  end 
of  the  spine,  this  cavity  is  composed  of  the  two  internal  iliac  fossae, 
which  belong  to  the  coxal  bones,  as  well  as  to  the  lesser  wings  of  the 
sacrum,  and  which  are  occupied  by  the  sigmoid  flexure  of  the  colon 
on  the  left,  the  ccecum  on  the  right,  and  by  some  folds  of  the  small 
intestines  on  both  sides. 

38.  The  lesser  basin  may  be  considered  as  part  of  a  canal  larger 
in  the  middle  than  at  its  two  extremities,  curved  anteriorly,  and  des- 
tined to  contain  the  internal  genito-urinary  organs,  the  rectum,  and 
the  hypogastric  and  sacral  vessels  and  nerves.  In  order  to  obtain 
a  clearer  idea  of  it,  it  is  well  to  follow  the  advice  of  M.  Chaussier, 
that  is  to  say,  to  remove  the  greater  basin  by  a  horizontal  section 
with  a  saw.  Like  the  external  surface,  it  may  be  divided  into  four 
regions,  and  circumscribed  in  the  same  way,  always  excepting  the 
lateral  regions,  which  leave  the  internal  face  of  the  ilium  above 
them, 

39.  The  ^interior  region  of  the  lesser  basin,  very  greatly  notched 
below  by  the  pubic  arch,  slightly  convex  from  above  downwards, 
and  concave  transversely,  comprises  the  posterior  face  of  the  bodies 
of  the  pubes,  of  the  ischio-pubal  rami,  and  of  the  obturator  mem- 
branes. We  may  remark,  I.  On  the  median  line  a  perpendicular 
crest,  more  or  less  salient,  formed  by  the  posterior  part  of  the  sym- 
physis pubis;  2.  Outwardly,  the  internal  obturator  fossa,  surmount- 
ed by  a  canal,  (and  not  a  simple  hole,)  oblique  from  behind  forwards, 
and  from  without  inwards;  through  this,  which  is  called  the  sub-pubal 
or  obturator  canal,  the  obturator  vessels  and  nerves  proceed  from 
the  interior  of  tlie  pelvis  to  the  inner  side  of  the  thigh. 

40.  The  posterior  region,  very  much  excavated,  is  represented 
by  the  anterior  surface  of  the  sacrum,  of  the  coccyx,  and  of  the  root 
of  the  sacro-ischiatic  ligaments. 

41.  The  lateral  regions,  formed  in  front  by  the  internal  face  of 
tlie  cotyloid  portion  and  the  rest  of  the  ischium,  behind  by  the  in- 
ner face  of  the  sacro-ischiatic  ligaments,  are  largely  opened  by  the  two 
sciatic  holes.  Of  these  two  openings,  one,  superior  ari^  the  largest, 
is  of  an  oval  shape,  and  gives  passage  from  within  the  pelvis,  1.  To 
the  pyramidal  muscle,  which  is  inserted  into  the  great  trochanter; 
2.  To  the  great  sciatic  nerve,  which  proceeds  to  be  distributed  on 
the  back  part  of  the  thigh,  the  outer  and  back  part  of  the  leg,  and 
to  the  whole  foot;  3.  To  the  gluteal  artery,  and  to  the  internal 
pubic  vessels  and  nerves:  the  other,  inferior,  much  smaller,  of  a  tri- 
angular shape,  is  filled  by  the  internal  obturator  muscle,  which  pro- 


OF  THE  PELVIS.  25 

ceeds  to  join  the  tendon  of  the  pyramidalis  in  the  digital  cavity  of 
the  great  trochanter,  and  by  the  pudic  vessels  and  nerves  which  re- 
enter the  pelvis  to  be  distributed  in  the  perineum. 

42.  Suppose  a  vertical  cut,  which  should  divide  the  lesser  basin 
into  four  equal  parts,  there  would  be  found  four  planes  inclined  to- 
wards each  other  at  their  points.  The  two  anterior  inclined  planes 
comprise  a  portion  of  the  lateral  regions  and  the  whole  of  the  an- 
terior region  of  the  excavation;  the  two  posterior  are  formed  by  the 
front  of  the  sacrum  and  coccyx,  by  the  sciatic  ligaments  and  notches, 
and  the  sacro-iliac  articulations.  It  is  always  on  two  of  these 
four  surfaces  that  the  extremities  of  the  diameters  of  the  fojtal  head 
glide,  during  parturition. 

§.  III.  StVaits  of  the  pelvis. 

43.  A.  Superior  strait.  The  sort  of  horizontal  circle  which  se- 
parates the  internal  surface  of  the  pelvis  into  two  parts,  is  called 
the  superior  or  abdominal  strait,  greater  strait,  or  margin  of  the 
pelvis :  formed  behind  by  the  sacro-vertebral  angle  and  the  ante- 
rior edge  of  the  lesser  wings  of  the  sacrum,  outwardly  by  the  rim 
which  limits  the  iliac  fossa  below,  in  front  hy  the  superior  posterior 
edge  of  the  body  of  the  pubis;  it  is  thick  or  rounded  in  the  first  por- 
tion described,  while  in  the  second  it,  on  the  contrary,  grows  thin,  and 
is  transformed,  so  to  speak,  into  a  crest. 

44.  Its  form  in  the  dried  pelvis  approaches  more  or  less  to  that 
of  an  oval,  of  the  heart  on  a  card,  or  of  an  ellipse;  but  with  the  soft 
parts  it  represents  a  triangle,  with  the  base  in  front. 

45.  Its  inclination  downwards  and  forwards,  when  the  woman  is 
on  foot,  varies  from  thirty-five  to  fifty  degrees.  This  inclination  is 
less  in  the  sitting  posture,  and  when  the  person  lies  down  or  bends 
forwards;  it  increases  in  pregnant  women,  in  those  who  make  use  of 
their  abdomen  to  support  heavy  burthens,  as  is  the  case  at  Paris 
with  the  women  who  sell  fruit,  vegetables,  fish,  &c.;  also  while  on 
the  knees;  and  whenever,  for  the  purpose  of  preserving  the  equili- 
brium, we  attempt  to  throw  the  upper  end  of  the  central  hne  of  the 
body  backwards. 

4G.  Its  axis,  is  an  imaginary  line  extending  from  the  umbilical 
region  to  the  lower  two-thirds  of  the  front  of  the  sacrum.  Every 
degree  of  incHnation  of  which  the 'plane  of  the  strait  is  susceptible,  is 
equally  applicable  to  its  axis,  since  the  latter  must  pass  through  the 
former.  The  upper  extremity  of  this  may  rise  higher  or  fall  lower, 
according  as  its  lower  extremity  recedes  from  or  approaches  towards 
the  point  of  the  coccyx.  In  this  respect  tliere  arc  infinite  shades  of 
difference,  which  must  not  be  lost  sight  of  in  practice,  whether  the 
D 


26  OF  THE  PELVIS. 

labour  be  terminated  spontaneously,  whether  the  child  must  be  turned, 
sought  for  by  the  hand,  or  delivered  with  instruments. 

47.  Its  principal  diameters  are  four  in  number  :  the  sacro-puhal, 
or  enter o-posterior^  which  extends  from  the  most  salient  point  of  the 
sacro-vertebral  angle  to  the  posterior  surface  of  the  symphysis  pubis  ; 
the  transverse'ov  bis-iliac,  which  passes  from  the  lower  edge  of  one 
iliac  fossa  to  a  point  diametrically  opposite;  the  two  oblique  or  mean 
diameters,  which  proceed  from  the  sacro-iliac  symphysis,  and  termi- 
nate behind  the  ileo-pectineal  eminence  of  the  opposite  side. 

48.  The  length  of  the  first  or  small  diameter  is,  according  to 
Madame  Boivin,  and  most  of  the  French  authors,  four  inches,  and 
four  inches  and  four  lines  according  to  Meckel ;  that  of  the  second 
is  five  inches;  that  of  the  third  from  four  inches  and  four  lines  to  four 
inches  and  a  half:  so  that  their  union  gives  a  circumference  of 
about  thirteen  inches  and  a  half.  But  these  dimensions  are  subject 
to  great  variety,  and  ought  not  to  be  understood  here  except  in  a 
very  general  manner. 

49.  B.  Inferior  strait.  The  inferior  strait,  lesser  strait,  perineal 
strait,  or  apex  of  the  pelvis,  is  formed  by  the  point  and  edges  of  the 
coccyx,  the  edges  of  the  sacro-sciatic  ligaments,  of  the  tuberosities 
of  the  ischium,  and  the  ischio-pubal  rami;  it  accordingly  presents 
three  triangular  projections,  the  coccyx  behind,  and  the  two  ischia 
on  the  sides  ;  as  well  as  three  indentations,  one  anterior,  very  deep, 
known  as  the  arch  of  the  pubis,  and  two  others,  posterior,  still  deep- 
er and  very  irregular  when  the  sciatic  ligaments  are  removed,  but, 
on  the  contrary,  quite  superficial  when  these  fibrous  bands  are  in 
their  natural  situation.  Its  form  is  precisely  like  that  of  the  heart 
on  a  playing-card;  only  it  may  become  oval  by  the  retreat  back- 
wards or  the  removal  of  the  coccygeal  triangle;  it  being  in  the  mean 
while  understood  that  the  widest,  most  open  part  of  these  figures  is 
always  turned  backwards. 

60.  Like  the  abdominal  strait,  the  inferior  strait  has  four  diame- 
ters :  one,  the  coccy-pubal,  or  antero-posterior,  is  measured  from  the 
point  of  the  coccyx  to  the  top  of  the  arch  of  the  pubis  ;  another,  the 
transverse,  or  fciVischiatic,  from  the  posterior  and  interior  part  of 
one  tuberosity  of  the  ischium  to  that  of  the  opposite  side  ;  the  two 
last,  or  the  oblique  diameters,  reach  from  the  i)oint  where  the  rami 
of  the  pubes  and  ischia  meet,  to  the  middle  of  the  edge  of  the 
sacro-sciatic  ligaments. 

61.  These  diameters  arc  generally  found  to  be  four  inches  each  ; 
however,  M.  Meckel  gives  to  tlie  first  fotit  iiiclies  and  four  lines, 
and  four  inches  six  lines  to  the  second.  M.  Dclpech  is  surely  incor- 
rect in  giving  as  the  mean  term  four  inches  and  a  half  to  one,  and 


OF  THE  PELVIS.  27 

five  inches  to  the  other.  The  mobility  of  the  coccyx,  and  the  elas- 
ticity of  the  sciatic  ligaments,  rentier  the  antero-posterior  diameter 
capable  of  being  prolonged  four,  six,  eight,  or  even  twelve  hnes, 
while  the  oblique  diameters  are  also  evidently  capable  of  being  elon- 
gated ;  the  transverse,  on  the  contrary,  T  have  always  found  to  be 
a  few  lines  less  than  four  inches.  Thus  the  circumference  of  the 
perineal  strait  should  be  about  twelve  inches. 

52.  In  general,  the  plane  of  the  inferior  strait  is  inclined  slightly 
upwards,  so  that  the  line  that  represents  it  crosses  that  of  the  supe- 
rior strait  in  front  of  the  symphysis  of  the  os  pubis;  however,  it  is 
sometimes  found  to  be  horizontal,  and  even  below  the  level  of  the 
coccyx. 

53.  The  axis  of  the  inferior  strait  is  represented  by  a  straight  line 
drawn  from  the  interior  of  the  pelvis,  and  cutting  the  middle  of  the 
coccy-pubal  diameter  at  right  angles;  the  upper  extremity  of  this 
line  most  commonly  rises  as  high  as  the  sacro-vertebral  angle,  and 
sometimes  is  found  to  be  even  parallel  with  the  spinal  column,  and 
may  approach  even  nearer  to  the  axis  of  the  superior  strait  in  very 
many  instances,  as  is  proved  by  the  late  researches  of  professor 
Naegele,  and  as  I  have  ascertained  for  myself. 

54.  In  order  to  obtain  correct  notions  on  this  subject,  it  is  neces- 
sary to  suppose  the  coccyx  depressed,  as  it  is  by  the  head  of  the 
foetus  at  the  moment  of  delivery;  the  posterior  extremity  of  the 
coccy-pubal  diameter  will  then  be  found  lower  than  its  anterior 
extremity,  and  the  axis  of  the  strait  descends  obliquely  from  behind 
forwards,  under  an  angle  of  from  fifteen  to  twenty  degrees,  passing 
from  the  anterior  face  of  the  first  or  second  piece  of  the  sacrum, 
through  the  middle  of  the  space  which  separates  the  anterior  parts 
of  the  tuberosities  of  the  ischia;  it  is  requisite,  further,  not  to  forget 
that  in  the  living  subject,  and  particularly  during  the  passage  of  the 
head,  the  obliquity  of  this  line  is  so  much  increased,  that  it  becomes 
almost  parallel  with  the  plane  of  the  superior  strait. 

§.  IV.  Dimensions  of  the  excavation. 

65.  The  anterior  wall  of  the  pelvic  cavity,  opposite  to  the  sym- 
physis of  the  pubis,  is  only  eighteen  inches  high,  but  more  outwardly  it 
is  near  three  inches:  the  depth  of  the  middle  portion  of  the  lateral 
regions  is  at  least  three  inches  and  a  half;  the  posterior  wall  is  at 
least  five  along  the  median  line,  following  the  curve  of  the  sacrum; 
and  only  four  in  a  straight  line,  from  the  promontory  to  the  point  of 
the  coccyx.  From  these  differences  it  is  manifest  that  the  inclina- 
tion of  the  straits  will  always  be  about  two  inches  and  a  half,  and  in 
an  inverse  proportion,  in  each  case;  for  the  pubis  cannot  be  depress- 


28  OF  THE  PELVIS. 

ed  towards  the  horizon  without  an  equal  or  apparent  degree  of  ele- 
vation of  the  coccyx  The  sacro-pubal  diameter  is  increased,  by  de- 
scending to  the  centre  of  the  excavation,  from  six  to  ten  lines,  on 
account  of  the  concavity  of  the  sacrum;  the  transverse  diameter,  on 
the  contrary,  diminishes  gradually  as  it  approaches  the  ischiatic, 
where  it  is  only  four  iriches.  The  oblique  diameters  alter  but  very 
little,  and  I  am  ignorant  of  the  facts  that  might  warrant  Mr  Meckel 
in  assigning  to  them  a  length  of  five  inches  and  four  lines. 

66.  As  the  anterior  face  of  the  sacrum  presents  us  With  a  cavity 
that  is  irregular  and  of  greater  or  less  depth,  it  is  easy  to  understand 
that  a  series  of  right  lines  that  should  fall  perpendicularly  upon  it 
could  not  be  parallel;  that  they  would  all  converge  towards  each 
other,  and  cross  at  angles  more  or  less  acute  in  front  of  the  articu- 
lation of  the  pubis,  with  the  exception  of  one  that  would  be  exactly 
horizontal.  For  the  same  reason,  we  may  imagine  that  the  plane 
represented  by  each  of  these  lines  must  have  an  axis  as  well  as  those 
of  the  straits,  and  consequently,  that  we  cannot  refuse  to  admit  an 
axis  of  the  excavation.  The  union  of  all  these  axes  would  give  a 
curve,  concave  anteriorly,  and  whose  two  extremes  would  be  repre- 
sented by  the  central  lines  of  the  superior  and  inferior  straits.  By 
viewing  the  axes  of  the  pelvis  in  this  light,  the  accoucheur  will  always 
have  before  him  the  direction  of  the  plane  of  the  anterior  face  of  the 
sacrum,  of  the  coccyx,  and  even  of  the  perineum;  and  as  this  is  the 
plane  that  directs  the  head  of  the  fcotus,  such  a  mode  of  regarding 
it  seems  to  me  more  simple,  and  much  more  useful  for  practice, 
than  the  method  indicated  by  certain  authors,  and  which  is  burthened 
with  geometrical  formulas*. 

§.  V.  Base  of  the  pelvis. 

57.  The  great  circumference  or  base  of  the  pelvis  looks  upwards 
and  forwards.  Its  plane  is  parallel  to  that  of  the  abdominal  strait. 
It  is  formed  posteriorly  by  a  notch,  in  the  bottom  of  which  is  seen 
the  base  of  the  sacrum,  and  which  is  naturally  filled  by  the  last  ver- 
tebra, the  ileo-lumbar  ligaments,  and  the  quadratus  luraborum  mus- 
cles; outwardly,  by  the  superior  edge  of  the  coxal  bone,  which  affords 

*  Vide  Deventer  ( Observ.  Sur  le  JUanuel  dea  Accouchemena,  1734),  who 
appears  to  have  been  the  first  to  indicate  that  the  cavity  of  the  pelvis  is  not  paral- 
lel to  the  axis  of  the  body;  MuUer  ( Collect,  de  Holier);  Roedercr  {De  Axis  pel- 
vis,  fyc.  Golt.  1751);  Smellie  {Treatise  on  the  TJieory,  ^c.  1771);  Lovret 
{Art  des  Accouchement,  1766);  Camper  {Translation  of  Mauriceau,  1759); 
Stein  {Art  d'AccouclicrtlSQA);  Lobstcin  {Bulletin  de  la  Faculte  de  Medecine 
dc  Paris,  1815);  Fi.itnant  (Thhc  de  M.  Guillemot,  Paris,  1824,  No,  164); 
Baker's  Drawing,  and  cspeciuliy  (he  learned  Memoir  of  M.  Nsuj^j^ie  {Bas  Wcth- 
liche  Becken,  Sfc.  Carlsruhe,  1825,  and  in  Archives  de  Medecine,  June  1827) 


OF  THE  PELVIS.  29 

attachment  to  the  three  broad  muscles  of  the  abdomen;  that  is  to 
say,  to  the  external  oblique  by  its  outer  lip,  to  the  transversalis  by 
its  inner  lip,  and  to  the  internal  oblique  by  its  interstice;  in  front  by 
the  great  hypogastric  notch  which  looks  from  above  downwards,  and 
from  without  inwards  ;  by  the  antero-superior  spine  of  the  ilium,  to 
which  are  attached  Poupart's  ligament,  the  sartorius  muscle,  and  a 
part  of  the  iliac  muscle  and  the  fascia  lata;  a  small  semilunar  de- 
pression for  the  passage  of  some  nervous  filaments  going  to  the 
thigh;  the  antero-inferior  spine  of  the  ilium,  which  gives  insertion  to 
one  of  the  roots  of  the  rectus  femoris  muscle;  a  second  depression 
for  the  passage  of  the  united  psoas  and  iliacus  muscles;  the  linea 
ileo-pectinea,  sometimes  scarcely  discernible,  and  sometimes  very 
salient,  and  which  receives  the  attachment  of  the  psoas  parvus ;  a 
third  depression  or  triangular  space  filled  up  by  the  origin  of  the 
pectineus  muscle,  and  correspont^ng  to  the  crural  vessel  and  nerves; 
the  pectineal  crista  or  postero-superior  edge  of  the  pubis,  oblique 
from  without  inwards,  which  forms  part  of  the  superior  strait,  and 
terminates  in  the  spine  of  the  pubis,  to  which  is  attached  the  outer 
pillar  of  the  abdominal  ring  and  the  rectus  abdominis  muscle;  lastly, 
by  the  upper  edge  of  the  symphysis  pubis. 

§.  VI.  Of  the  dimensions  of  the  pelvis,  unconnected  with  its  axes 
or  straits. 

58.  The  space  comprised  between  the  two.  anterior  inferior  spines 
of  the  ilia  measures  eight  or  nine  inches;  that  between  the  antero- 
superior,  from  nine  to  ten;  and  from  ten  to  eleven  between  the  middle 
portions  of  the  crista?  of  the  ilia.  The  length  of  the  crest  of  the 
ilium,  following  its  course  from  the  postero-superior  spine  to  the 
antero-superior  tuberosity  is  eight  inches,  and  six  inches  in  a  straight 
line.  The  base  of  the  sacrum  is  four  inches  across,  and  two  inches 
and  a  half  from  front  to  rear.  From  the  middle  of  the  iliac  crista 
to  the  tuberosity  of  the  ischium  is  seven  inches,  and  the  margin  of 
the  excavation  cuts  this  line  into  two  nearly  equal  portions;  the  sym- 
physis jiubis,  which  is  eighteen  lines  high,  is  only  half  an  inch  thick. 
The  arch  of  the  same  name  is  from  three  and  a  half  to  four  inches 
wide  at  its  base  where  it  blends  with  the  bis-ischiatic  diameter,  and 
only  ten  or  twelve  lines  at  its  apex;  its  height  is  two  inches  and  a 
half,  and  the  bony  semicircle  of  which  it  is  composed  is  folded  for- 
wards and  outwards,  as  if  it  had  been  turned  in  this  way  by  the  pas- 
sage of  some  hard  and  rounded  body,  while  still  in  a  soft  and  plastic 
state. 

§.  VII.  Differences  of  the  pelvis,  in  respect  to  ages,  sekes  and 
species. 


30  OF  THE  PELVIS. 

69.  At  birth  the  pelvis  is  extremely  narrow  and  very  much  elon- 
gated; the  curves  of  the  iliac  crista  arc  scarcely  begun,  and  the 
position  of  the  ilium  is  almost  vertical;  the  pelvic  cavity  is  conoidal 
and  not  excavated;  the  sacrum  is  so  much  elevatpd  that  a  horizontal 
line  passes  under  the  point  of  the  coccyx  at  the  same  time  that  it 
rests  on  the  top  of  the  pubis;  its  transverse  are  much  shorter  than 
its  antero-posterior  diameters.  The  bones  are  still  bordered  vs^ith 
thick  layers  of  temporary  cartilages,  and  the  whole  is  so  compress- 
ible that  the  dimensions  of  the  pelvic  extremity  of  the  foetus  may 
easily  accommodate  themselves  to  those  of  the  maternal  pelvis  dur- 
ing labour.  After  two  or  three  years,  some  new  osseous  points 
are  produced,  but  they  do  not  always  coalesce  entirely  with  the  rest 
of  the  coxal  bone  until  the  age  of  fifteen  or  twenty  years.  The 
spine  of  the  pubis  has  even  been  seen  to  acquire  a  length  of  six 
or  eight  lines,  and  remain  movable  like  an  independent  piece,  which 
has  caused  it  to  be  compared  to  the  marsupial  bones  of  the  didel- 
phic  animals. 

60.  It  is  therefore  not  until  the  fifteenth  or  eighteenth  year  that 
the  evolution  and  union  of  the  several  osseous  points  of  the  pelvis 
are  entirely  completed;  so  that  previously  to  this  age  it  is  not  the 
height  of  prudence  to  expose  a  woman  to  become  pregnant. 

61.  In  men  the  pelvis  always  retains,  in  respect  to  its  form,  the 
same  characters  it  had  in  infancy.  All  its  parts  are  narrower  and 
deeper  than  they  are  in  women;  the  coccy-pubal  diameter,  is  only 
three  inches  and  a  quarter,  the  bis-ischiatic  three  inches,  and  the 
bis-iliac  four  and  a  half.  There  are  only  seven  or  -eight  inches  be- 
tween the  antero-superior  spinous  processes,  and  eight  or  nine  from 
the  middle  of  one  iliac  crista  to  the  opposite  one.  The  arch  of  the 
pubis  is  straight,  not  wide  in  front,  and  almost  triangular;  the  sym- 
physis of  these  bones  is  at  least  two  inches  long,  and  the  thyroid  for- 
amen approaches  also  to  tlie  form  of  a  triangle;  the  sacrum  is  much 
less  curved,  tlie  excavation  not  so  deep,  and  the  superior  strait  more 
inclined,  rounder,  more  like  an  oval  or  a  circle;  the  iliac  fossa3  are 
more  hollow,  the  great  trochanters  are  not  so  far  apart,  tljc  bones 
in  general  thicker,  and  especially  more  uneven  on  their  outer  sur- 
faces; in  the  male  pelvis,  every  thing  bespeaks  strength  and  solidity, 
and  is  so  arranged  as  to  render  progression  easy. 

62.  In  women,  on  the  contrary,  the  articulations  are  not  so  com- 
pact, they  are  thinner;  the  iliac  crista;  are  wider,  and  turned  outwards 
more  than  the  base  of  the  thorax,  which  gives  a  greater  breadth  to 
the  hips.  The  trochanters  widely  separated,  by  increasing  the 
transverse  extent  of  the  base  of  support  of  the  body,  also  render 
walking  more  diflicult,  and  give  to  the  sex  a  gait  that  is  altogether 


OF  THE  PELVIS.  31 

peculiar;  in  a  word,  nature  seems  here  to  have  sacrificed  strength 
and  ease  of  motion  to  the  advantage  of  pregnancy  and  parturition. 

63.  In  the  male  pelvis  the  coccyx  early  unites  with  the  point  of 
the  sacrum,  and  the  three  symphyses  frequently  anchylose  in  old 
age;  in  women  the  sacro-coccygeal  articulation  remains  movable 
even  until  the  period  of  decrepitude;  the  sacro-iliac  and  pubic  arti- 
culations are  rarely  anchylosed,  even  at  the  most  advanced  age. 

64.  In  thin  women,  and  in  those  who  are  aery  tall^  the  pelvis  is 
not  so  wide,  and  resembles  more  nearly  that  of  the  male,  than  in 
persons  of  a  short  and  well  proportioned  stature;  which,  in  the  opi- 
nion of  the  common  people,  causes  the  former  to  bear  children  with 
more  difficulty  than  the  latter. 

65.  The  pelvis  of  animals  is  notably  different  from  that  of  the 
human  species.  If  Roussel  and  some  other  philosophers  had  paid 
attention  to  this  circumstance,  they  doubtless  would  not  have 
maintained  that  labour  requires  no  aid,  because  brutes  are  delivered 
of  their  young  without  needing  assistance,  and  almost  without  pain. 
In  fact,  in  most  quadrupeds,  the  pelvis,  scarcely  curved,  in  reality 
presents  only  one  single  axis;  the  sacrum  is  almost  parallel  with  the 
spine;  the  straits  are  only  slightly  inclined,  and  the  walls  of  the  pel- 
vic canal  are  nearly  all  of  the  same  length;  the  coxal  bones  are  so 
narrow,  straight  and  elongated,  that  there  is,  so  to  speak,  no  iliac 
fossa;  so  that  delivery  is  not  exposed,  in  these  species,  to  the  same 
hazards  as  in  man. 

G6.  It  must  not  be  thought,  however,  that  nature  changes  thus 
suddenly,  and  without  gradation,  the  forms  of  organs  in  a  series  of 
creatures ;  in  the  monkeys,  the  pelvis,  by  differing  from  that  of  the 
inferior  animals,  is  found  already  to  approximate  somewhat  to  the 
character  of  the  human  pelvis  ;  it  is  only  by  ascending  the  zoological 
scale,  that  we  find  it  gradually  becoming  more  perfect ;  its  various 
shades  may  be  traced  in  the  ourang-outang,  the  Bosjesmans,  who 
from  their  organization  seem  to  constitute  the  connecting  Hnk  be- 
tween the  monkey  and  man,  in  the  Ethiopian  or  Negro,  and  the 
Malay  or  Japanese  races,  before  coming  up  to  the  Caucasian  race, 
in  which  it  is  removed  as  far  as  possible  from  the  form  observed  in 
the  other  mammiferas*  ;  whence  we  have  a  right  to  presume  that 
parturition  is  so  much  the  more  painful,  as  the  species  is  more  per- 

*  On  this  subject  the  reader  may  consult  an  interesting  work  by  Dr  Wro- 
lick,  who  had  in  Holland  an  opportunity  of  comparing  the  pelvis  of  the  Negro, 
tlie  Javanese,  Bosjesmans,  Mustee,  ani^the  Hottentot  Venus,  who  was  seen  by 
many  persons  at  Paris,  and  who  was  a  veritable  Howzouanasse.  Le  Bulletin 
des  Sciejices  Medicalea  for  February  1827  contains  an  extract  from  this  memoir, 
which  is  also  to  be  found  in  the  bookstores  at  Paris. 


32  OF  THE  PELVIS. 

feet,  and  vice  versa:  a  compensation  as  admirable  as  it  is  singular, 
and  which  occasions  danger  in  some  measure  to  multiply  and  accu- 
mulate around  an  animal  in  proportion  as  his  intelligence  becomes 
more  perfect. 

67.  In  the  kangaroo  and  other  marsupial  animals,  the  pelvis  is 
prolonged  in  front  by  means  of  the  spines  of  the  pubes,  which  form 
two  separate  bones,  and  support  the  pouch,  in  which  the  second 
gestation  of  these  anynals  is  effected ;  its  narrowness  in  the  cabiai 
and  the  mole  would  not  admit  of  the  escape  of  the  young ;  but  during 
gestation  the  pieces  are  disjoined,  and  separate  considerably  from 
each  "other.  In  the  cetacean  there  are  only  some  traces  of  a  pelvis ; 
and  in  birds,  reptiles  and  fishes,  where  it  serves  only  in  depositing 
the  egg,  we  find  it  gradually  decomposed,  until  it  disappears. 

§.  VIII.  Of  the  recent  pelvis. 

68.  The  soft  parts  which  naturally  cover  the  interior  of  the  pelvis, 
produce  certain  changes  in  its  form  and  dimensions,  the  knowledge 
of  which  is  indispensable  to  the  accoucheur. 

69.  The  inferior  strait,  for  example,  is  shut  up  by  a  kind  of  par- 
tition, which  is  called  the  floor  of  the  pelvis ;  a  partition  which 
diminishes  the  height  of  the  excavation,  and  seems  to  be  the  anta- 
gonist of  the  diaphragm,  or  rather  of  the  abdominal  muscles,  during 
the  efforts  of  inspiration,  defaecation,  and  the  emission  of  urine,  and 
during  parturition. 

70.  This  floor  is  composed  of  two  fleshy  layers:  one,  superior, 
concave  above,  is  formed  by  the  levator  ani  and  ischio-coccygeal 
muscles;  the  other,  inferior,  concave  below,  is  composed  of  the 
sphincter  ani,  transversus  perinei,  ischio-cavernosus,  and  constrictor 
vaginffi  muscles.  Tliere  also  are  found  the  lower  hemorrhoidal  and 
the  internal  pudic  vessels  and  nerves,  with  fat  and  cellular  tissue  in 
greater  or  less  abundance. 

71.  Lastly,  it  is  pierced,  as  it  were,  on  the  medium  line  by  the 
urethra,  the  vagina,  and  the  termination  of  the  rectum.  Its  lower 
face  is  lined  by  an  aponeurosis  which  seems  to  rise  from  the  great 
sciatic  ligament,  and  the  inner  lip  of  the  pubic  arch,  and  the  strcngtii 
of  which,  although  very  variable,  will  be  found  greatest  as  it  is  exa- 
mined nearest  to  its  origin.  A  portion  of  the  pelvic  aponeurosis 
covers  its  upper  region,  and  I  think  with  Camper  and  M.  Desor- 
mcaux,  that  tlie  disposition  of  the  fibrous  lamina!  may  exert  some  in- 
fluence on  the  promj)titudc  or  tardiness  of  labour,  particularly  in 
women  who  have  never  had  childlbn* 

72.  The  superior  strait  is  more  elevated  in  the  recent  than  in 
the  dried  skeleton,  by  (he  cut  in    thickness  of  the  psoab  muscles, 


OF  THE  PELVIS.  33 

which,  with  the  iliac  vessels,  form  a  sort  of  column,  extending  from 
the  sides  of  the  sacro-vertebral  angle,  to  the  linea  ilio-pectinea,  so 
as  in  a  considerable  degree  to  contract  the  bis-iliac  diameter,  and 
also  to,  increase  the  inclination  of  the  strait  very  much.  Instead  of 
being  elliptical,  or  representing  an  oval  whose  large  extremity  should 
be  turned  backwards,  this  strait  is  now  almost  circular,  or  in  the 
shape  of  a  triangle  with  the  base  forwards;  the  sacro-iliac  notches 
scarcely  exist,  and  the  sacro-vertebral  angle  is  much  less  prominent 
than  is  commonly  supposed,  from  the  idea  formed  of  it  upon  inspec- 
tion of  the  dried  pelvis. 

73.  From  the  researches  to  which  I  have  devoted  myself,  and 
whose  results  have  been  already  made  known,  I  find  that  the  en- 
trance of  the  pelvis  is  widest  between  the  ilio-pectineal  eminences; 
at  this  point  its  transversal  diameter  is  four  inches  and  some  lines, 
while  the  bis-iliac  diameter,  properly  so  called,  is  only  three  inches 
and  a  half  to  four  inches.  Beneath  the  promontory  and  the  psoas 
muscles,  the  transverse  diameter  is  really  five  inches,  and  the  con- 
cavity of  the  sacrum  gives  quite  as  great  a  length  to  the  antero-pos- 
terior  diameter. 

74.  The  bottom  of  the  excavation  is  of  a  lozenge  shape,  with  an- 
gles corresponding  on  the  one  hand  to  the  ischiatic  spines,  and  on  the 
other  to  the  middle  line  of  the  sacrum  and  posterior  surface  of  the 
pubic  symphysis.  These  four  angles  indicate  the  place  of  union  of 
the  four  inclined  planes,  which  thus  represent  four  triangles,  tend- 
ing to  approach  each  other  at  their  points. 

76.  The  sacral  vessels  and  plexus,  as  well  as  the  pyramidalis  mus- 
cle, are  found  in  the  posterior  triangles  :  the  anterior  planes  enclose 
the  internal  obturator  muscles  and  part  of  the  levator  ani.  The 
pelvic  fascia  is  exactly  applied  over  alljhese  parts ;  an  abundant 
layer  of  cellular  tissue,  in  which  are  imbedded  the  internal  iliac  ves- 
sels, the  hypogastric  flexus  and  arteries,, a  layer  which,  by  the  de- 
position of  fat,  sometimes  becomes  so  thick  as  to  diminish  the  cavity, 
and  thus  render  labour  more  difficult,  lines  the  whole,  and  is  sepa- 
rated from  the  vi§cera  by  the  Intermediate  peritoneum. 

§.  IX.  Uses  of  the  pelvis.  •,  • 

76.  The  different  bony  pieces  which  compose  the  pelvis  are  sus- 
ceptible of  only  a  very  slight  movement  upon  each  other;  notwith- 
standing assertions  to  the  contrary,  the  kind  of  sUding  that  takes 
place  between  the  sacrum  and  coxal  bones,  as  well  as  between  the 
ossa  pubis,  in  consequence  of  a  fall  upon  the  feet,  for  example,  can- 
not in  any  manner  be  compared  to  articular  motion  of  whatsoever 
species. 
E 


34  OF  THE  PELVIS. 

77,  The  pelvis  is  the  base  of  the  trunk  ;  it  forms  a  complete  ring, 
the  posterior  half  of  which,  says  M.  Desormeaux,  supports  the  en- 
tire weight  of  the  body,  while  the  anterior  serves  as  its  abutment,  so 
that  the  weight  of  the  trunk  and  thoracic  members,  transmitted 
through  the  vertebral  column  to  the  sacrum,  expends  itself  first  on 
the  ossa  ilia,  and  next  on  the  pubes,  which  press  against  each  other 
with  more  or  less  force. 

78.  To  the  lateral  parts  of  this  circle  are  attached  the  pelvic 
members,  which  in  certain  postures,  in  their  turn,  support  the  whole 
of  this  burthen,  whether  conjointly  or  separately.  This  use  of  the 
pelvis,  though  interesting  to  the  physiologist,  is  still  more  so  to  the 
accoucheur,  for  it  accounts  for  the  vicious  and  singular  forms  that 
are  sometimes  assumed  by  the  pelvic  cavity,  when  ossification  either 
proceeds  too  slowly  or  retrogrades.  Another  use  of  the  pelvis  is 
ito  enclose  and  protect  the  bladder,  the  rectum,  the  uterus,  the  tubes, 
and  ovaries.  During  pregnancy  it  supports  the  womb,  and  main- 
tains it  in  a  proper  attitude.  During  labour  it  gives  passage  to  the 
infant,  by  impressing  upon  it  the  most  favourable  direction,  and  by 
affording  a  point  cfappui  to  the  soft  parts  of  generation. 


SECTION  4. 
Of  the  Deformed  Pelvis. 

79.  It  would  perhaps  be  more  rational  not  to  speak  of  deformi" 
ties  of  the  pelvis,  until  we  should  come  to  treat  of  difficult  labour  ; 
but  the  custom  of  examining  them  immediately  after  treating  of  the 
natural  conformation  having  prevailed  for  so  long  a  time,lll|k^  not 
felt  myself  at  liberty  to  deviate  from  it. 

80.  The  pelvis  is  deformed  whenever  it  is  sufliciently  altered,  ei- 
ther in  its  natural  form  or  dimensions,  to  render  parturition  diflicult, 
dangerous,  or  impossible.  In  this  view,  a  pelvis  may  be  mal-formcd, 
although  its  conformation  be  regular,  and  it  may  have  a  mal-confor- 
mation,  although  it  bo  not  deformed.  Nevertheless,  these  two  con- 
ditions being  almost  always  united,  it  has  happened  that  the  books 
have  commonly  confounded  them  both  together:'  Sacombe,  it  is  true, 
desired  to  see  a  distinction  made  between  mal-configu ration  and 
mal-conformation;  but  this  distinction  being  purely  grammatical,  has 
not  been  adopted,  and  scarcely  deserves  to  be  combated. 

81.  The  direction  of  the  axes  and  planes  of  the  pelvis,  the  di- 
mensions of  its  diameters,  and  even  its  form,  are  doubtless  far  from 
being,  in  all  pelves,  exactly  bin)ilar  to  those  I  have  mentioned  above  ; 
but  a  few  lines  more  or  less,  an  inclination  more  or  less  dncided,  a 


"^  OF  THE  PELVIS  35 

islight  mal-conformation,  not  sufficient  to  prevent  a  labour  from  ter- 
minating without  danger — it  may  be  conceived  tliat  these  deformities, 
properly  so  called,  must  be  pretty  rare. 

All  deformities  of  the  pelvis  may  be  referred  to  its  excess  of  am- 
plitude, its  narrowness,  or  the  faulty  direction  of  its  axes. 

§.  I.  Deformity  from  excess  of  amplitude. 

82.  It  would  seem  at  the  first  glance,  that  a  very  large  pelvic 
ought  to  be  rather  advantageous  than  unfavourable  in  pregnancy 
and  labour ;  but  observation  and  reason  prove  that  this  is  not  always 
the  case. 

During  gestation,  the  womb,  being  less  completely  supported, 
may  be  upset,  either  backwards  or  forwards,  as, long  as  its  dimen- 
sions do  not  exceed  those  of  the  abdominal  strait,  and  it  may  in- 
cline in  any  direction  after  the  fourth  month. 

A  large  pelvis  favours  the  descent  of  the  womb  anil  the  prompt 
termination  of  labour,  and,  consequently,  exposes  the  woman  to  all 
those  accidents  which  occasionally  follow  rapid,  delivery  ;  that  is  to 
say,  to  inertia,  inversion  of  the  uterus,  and  hemorrhage. 

,  I  agree,  nevertheless,  with  Madame  Lachapelle,  that  these  inconr 
veniences  have  been  exaggerated,  that  it  is  generally  easy  to  prevent 
them,  and  that  the  falling  of  the  child,  the  premature  detachment  of 
the  placenta,  and  the  rupture  of  the  cord  have  perhaps  never  been' 
produced  by  this  cause  rather  than  by  some  other. 

§.  II.  Deformity  from  want  of  amplitude. 

83.  It  has  been  incorrectly  maintained  that  tb|  pelns  cannot  be 
contracted  in  one  dii-cction  without  becoming  larger  in  another,  and 
that,  consequently,  the  circumferences  of  its  straits  never  vary. 
Observation  has  superabundantly  demonstrated  tha^  in  a  consider.- 
ablc  number  of  women,  the  pelvis  retains,  after  the  age  of  puberty, 
most  of  the  characters  it  had  in  infancy,  and  that  its  form  ap- 
proaches more  or  less  to  that  of  the  male;  and  so  far,  its  absolute 
capacity  remains  less  than  it  ought  to  be  in  the  normal  state. 

Besides,  since  it  is  fully  admitted  that  there  may  bo  e:sces8ive 
capacity,  I  sec  not  why  there  should  be  any  repugnance  to  assert 
that  it  may  also  be  too  small  in  all  its  directions  at  once  ;  however, 
this  general  and  regular  narrowness  is  pretty  rare,  and  I  have  not  yet 
learned  that  it  has  ever  involved  the  necessity  of  a  serious  operation. 

84.  It  may  be  said,  therefore,  that  relative  or  partial  sinallness  js 
the  only  kind  that  involves  real  danger  ;  it  is  most  conmionly  met  with 
at.the  superior  strait,  less  common  at  the  perineal  strait,  and  met  with 
still  less  frequently  in  the  excavation  ;  it  may  aifect  the  antero-pos 


36  OF  THE  PELVIS. 

tenor,  transverse  or  oblique  diameters,  either  taken  separately,  or 
several  of  them  conjointly. 

85.  According  to  my  researches  I  find  that  it  mo^t  frequently 
affects  the.oblique  diameters  of  the  superior  strait,  and  more  generally 
one  than  both  of  them  at  once  ;  shortening  of  the  transverse  dia- 
meter is  the  rarest  of  all,  and  has  perhaps  never  been  met  with 
alone. 

86.  These  different  deformities  give  to  the  entrance  of  the  pelvis 
forms  as  various  as  they  are  easy  to  conceive  of.  Shortening  of  the 
antero-posterior  diameter  may  depend  on  too  great  a  saliency  of  the 
sacro-vertebral  angle,  and  then  the  strait  is  cordiform  ;  jf,  at  the  same 
time,  the  syrayphysis  of  the  pubis  is  driven  backwards,  the  pelvis 
exhibits  the  appearance  of  the  figure  oo,  lying  in  a  horizontal  posi- 
tion. When  both  of  the  oblique  diameters  are  affected,  the  bodies 
of  the  pubis,  by  approaching  the  promontory,  may,  if  there  be  no 
derangement  of  the  symphysis,  give  to  the  strait  the  shape  of  a  tri- 
angle, a  trapezium,  or  a  trefoil,  according  as  the  ends  of  the  bis-iliac 
diameter  shall  form'nngles  more  or  less  acute  or  rounded.  These 
pelves,  which  have  been  denominated  trilobated  or  trifoliated,  also 
present  this  peculiarity,  that  the  three  segments  are  sometimes 
equal,  while  at  other  times  the  anterior  portion,  or  the  right,  or  left, 
is  nmch  smaller  than  the  other  two.  It  may  also  happen,  that  the 
two  acetabula  may  tend  to  approach  each  other,  in  proportion  as 
they  approximate  towards  the  sacrum  ;  the  pubes  in  this  case,  bent 
at  a  right  angle  to4he  ileo-pectineal  eminences,  project  from  one 
inch  and  a  half  to  two  inches  in  front,  become  parallel  to  the  antero- 
posterior diameter,  and  have  between  them  a  space  of  only  a  few 
lines.  The  figures  of  two  pelves  of  this  sort  may  be  seen  in  a  dis- 
sertation by  Weideman.  Madame  Boivin  has  given  a  design  of  one 
that  belongs  tcrtlie  same  category  ;  but  the  most  extraordinary  one 
is  that  belonging  to  M.  Jeuffrion,  and  a  model  of  which  in  plaister 
was  deposited  by  M.  Maygrier  in  the  Museum  of  the  Ecole  de  Me- 
decine.  In  this  pelvis  the  two  pubes  proceed  directly  backwards  to 
the  points  whore  they  unite  with  the  ilia,  that  is,  to  the  extent  of  a 
full  inch  and  a  half;  near  the  acetabula,  ap  well  as  immediately 
behind  the  symphysis,  the  interval  between  tbem  is  only  three  lines  ; 
all  this  portion,  therefore,  is  completely  foreign  to  the  circle  of  the 
strait,  and  the  anforo-postcrior  diameter  measures  in  reality  only  two 
inches  and  a  half,  instead  of  five,  as  would  have  been  supposed  had 
it  been  measured  externally  during  life.  .*  * 

87;  When  only  one  of  tlie  oblique  diameters'  is  deformed,  it  com- 
monly produces  ^a  disposition  that  it  is  highly  important  to  notice. 
If,  for  example,  the  contraction  occurs  on  the  riolit  side,  the  left 


OF  THE  PELVIS.  ^'-  37 

may  present  an  excess  of  amplitude.  In  this  case,  it  is  clear,  that 
if  the  head  presents  with  the  occiput  turned  to  the  right,  the  labour 
miorht  not  come  to  a  conclusion  without  assistance;  whereas  if  it  had 
presented  to  the  left,  nature  would  have  sufficed  for  her  own  relief. 
This  remark  indicates  with  sufficient  clearness,  that  in  order  to  pro- 
cure an  easy  delivery  for  a  woman  with  such  a  conformation,  it  is 
only  necessary  to  turn,  and  bring  down  the  child  in  the  first  or  se- 
cond position  of  the  feet ;  so  that  the  occiput  may  correspond  to  the 
largest  side  of  Hhe  strait.  It  also  explains  why  a  woman  who  has 
been  spontaneously  delivered  of  her  first  child,  may  not  perhaps  get. 
through,  in  a  second  labour,  without  symphysiotomy  or  the  Caesarian 
section,  a,nd  vice  versa.  '  •  ., 

88.  In  1825  I  was  requested  to  attend  a  woman  who  had  been 
in  labour  for  two  days  ;  the  head  would  not  engage;  I  sought  for  the 
feet,  and  terminated  the  labour.  In  1826,  the  same  woman  was 
brought  to  the  hospital  de  la  Facultc,  having  been  four  days  in  labour. 
The  waters  were  gone  off,  and  the  head  was  strongly  engaged  ;  the 
womb,  being  very  closely  applied  to  the  foetus,  would  not  allow  the 
operation  of  turning  ;  the  application  of  the  forceps  was  attempted 
by  MM.  Desormeaux,  Deneujt  Mid  myself,  but  nothing  could  induce 
the  head  to  descend.  This  woman,  who  became  pregnant  again  in  ^ 
1827,  gave  me  timely  notice  when  her  labour  came;on  ;  I  felt  for** 
the  feet,  and  every  thing  was  promptly  and  happily  teijiiinated.  The 
different  issue  of  these  throe  labours  depended  upon  this,  that  in  one 
case,  4he  back  part  of  the  head  presenting!  to  the  right,  where  the 
pelvis  was  greatly  Contracted,  could  ndt  pass  through  the  strait, 
while  in  the  other,  by  turning  the  occiput  to  the  left,  where  the 
natural  dimensions  were  preserved- the  passage  of  the  head  was  not 
impossible.     ,  ^ 

89.  Unless  the  sacrum  itself  be  contracted,  it  is  rarely  that  a  les- 
sening of  the  transverse  diameter  of  the  abdominal  strait  is  capable 
of  interfering  With  the  escape  of  the  child.  There  are  almost  always 
to*b9  found  more  than  four  inches*  between  the  iliac  fossa;,  and  this 
k^a  of  deformity  only,  occas'ioiR  an  increase  of  the  sacro-pubal 
diameter,  by  giving  to  the  strait  the  form  of  an  oval,  or  a  greatly 
elongated  heart.  -^    ' 

90.  Sometimes  the  narrowing  affects  only  one  side  of  the  pelvis, 
as  is  seen  in  a  specimen  in  the  museum  of  the  FaculU:  in  that  case 
the  deformity  comprises  both  the  greater  and  lesser  basin. 

91.  All  these  deformities  may  be  combined  in  various  ways,  or 
exist  singfy,  and  in  very  different  degrees.  Charles  Bell  tells  us 
that  in  the  pelvis  of  a  woman  whb'hatl  been  long  affected  with  osteo- 
malacia, there  remained  a  space  of  about  three  lines  only  in  the 


38  OF  THE  PELVIS. 

antero-posterior  diameter,  and  only  about  half  an  inch  betwixt  the 
iliac  fossa;*.  Baudelocque  cites  a  case  in  which  there  were  only 
nine  lines  from  the  sacrum  to  the  pubis.  A  contraction  almost  as 
great  as  the  one  just  mentioned,  is  observable  in  a  specimen  that  I 
saw  in  the  Museum  de  I'Ecole  de  Medecine  ;  however,  any  body 
can  understand  how  many  shades  there  may  be  between  these  ex- 
treme contractions  and  the  normal  dimensions  of  the  pelvis.        *  <*». 

92.  The  inferior  strait  is  perhaps  more  frequently  enlarged  than* 
contracted;  when  the  base  of  the  sacrum  is  depressed  towards  th&\ 
pubis,  or  the  pubis  driven  backwards  towards  the  sacrum,  it  almost 
always  is  in  the  direction  of  a  see-saw  movement,  which  separates 
the  coccyx  more  or  less  from  the  top  of  the  pubic  arch.  Although 
it  may  be  laid  down  as  a  general  rule  that  the  inferior  strait  enlarges 
while  the  superior  strait  contracts,  it  is,  nevertheless,  possible  that 
they  may  both  be  narrowed  at  the  same  time,  and  that  too  in  their 
corresponding  (fiameters. 

93.  The  approximation  of  the  tuberosities  of  the  ischia  towards 
each  other,  too  great  a  straightness,  or  a  triangular  form  of  the  pubic 
arch,  coinciding  almost  always  with  a  long  symphysis  pubis,  give 
birth  to  what  is  called  barrurc,  the  most  common  and  dangerous  of 
alkjthe  deformities  of  the  perineal  strait ;  for  as  the  fcctal  head  must 
pass  throughJbe  pubic  arch,  rather  than  behind  the  ischia  where 
the  soft  parts  arrest  it,  the  barrure  renders  the  delivery  extremely 
difficult ;  the  retroversion  of  the  coccyx  does  no  good  in  this  case, 
and  if  the  child  is  born  .at  last,  it  is  at  the  expense  of  an  extiensive 
laceration  of  the  perineum. 

94.  The  coccyx,  also,  very  often  becomes  almost  horizontalKjanJ 
may,  by  rising  upwards,  more  or  less  affect  the  coccy-pubal  dnune^ 
ter,  especially  where  the  base  oi||thc  sacrum  is  thrown  back.*^  It 
also  pretty  frequently  happens  that  one  of  the  ischia  with  its  ramus 
inclines  towards  the  centre  of  the  strait,  while  the  opposite  ischium 
and  the  coccyx  do  not  alter  their  position.  In  fine,  the  varicties>Qf 
form  are  here  less  numerous  tljjin^in  the  supoiior  strait ;  but  the 
degrees  of  contraction  should  be  understood  in  the  same  manner. 

95.  Faults  of  the  excavation  coincide  almost  always  with  the  con 
tractions  of  one  or  the  other  strait,  and  sometimes  with  both  of  them 
simultaneously.  They  depend  cither  on  too  great,  or  on  an  insuffi- 
6ient  curvature  of  the  sacrum. 

96.  In  the  former  case  the  bone  is  ^cnt.  ns  i(  wore,  upon  its  an- 

*  In  a  woman  who  had  already  had  six  childrcji,  M.  Nx>gclo  saw  such  a  do- 
formity  of  the  pulvia  us  to  luuvc  unly  two  VmoH  on  lliu  lell,  uiid  »ix  lines  on  thu 
riglit  between  Uio  fourth  lumbar  vorteb/aWd  thu  superior  brim  of  the  symphysis 
pubis. 


OF  THE  PELVIS.  39 

, terior  face,  and  the  sacro-pubal  or  coccy-pubal  diameters  are  to  a 
greater  or  less  degree  diminished,  while  the  antcro-posterior  diame- 
ter  is  found  to  be  larger  than  natural ;  in  other  instances,  although 
very  greatly  curved,  it  is  not  the  less  removed  to  a  great  distance 
from  the  pubis,  whether  at  its  base  or  apex. 

Tn  the  second  case,  the  anterior  face  of  the  sacrum  being  actually 
plane,  or  even  slightly  convex,  as  may  be  seen  in  a  specimen  belong- 
ing to  the  collection  of  the  Ecole^  the  pelvic  cavity,  instead  of  dilating 
betwixt  its  straits,  becomes  smaller,  or  on  the  other  hand,  it  enlarges 
regularly,  from  the  promontory  to  the  point  of  the  coccyx,  according 
as  the  base  of  the  sacrum  seems  to  have  see-sawed  forwards  or 
backwards. 

97.  When  the  sacrum  is  too  concave,  and  when  both  the  straits 
are  narrowed,  if  the  head,  by  means  of  great  efforts,  comes  down  to 
the  excavation,  it  stops  there,  becomes  locked,  can  neither  advance 
nor  retreat,  and  renders  the  labour  so  dangerous  that  even  the  Ca3- 
sarian  operation  itself  might  be  insufBcient  for  its  termination.  If 
it  be  too  straight,  and  the  lower  strait  is  too  much  contracted,  the 
head  will  descend  at  first  very  promptly,  but  as  it  passes  through  a 
eonical  canal,. it  will  soon  be  arrested,  and  with  difficulty  clear  the 
apex. 

98.  Whenever  narrowness  of  one  of  the  straits  coincides  with  ex- 
cessive amplitude  of  the  other,  the  progress  of  the  labour  is  neces- 
sarily perplexed.  Is  the  abdominal  strait  faulty  through  insufficient 
amplitude  ?  the  head  will  long  repiain  arrested  at  it,  but  will  pass 
through  at  last ;  then,  meeting  almost  no  resistance,  it  will  traverse 
the  apex  of  the  pelvis  with  great  celerity,  at  a  moment  perhaps  when 
the  accoucheur,  judging  of  the  duration  of  the  labour  by  the  time 
that  has  been  already  occupied,  is  informing  the  assistants  that  seve- 
ral hours  must  elapse  before  it  can  .be  concluded.  Has  the  inferior 
strait,  on  the  contrary,  lost  its  dimensions  ?  the  fcctus  engages  with 
extreme  quickness,  and  the  practitiorier,  who  does  not  suspect  the 
real  condition  of  the  pelvis,  announces  that  the  woman  will  speedily 
be  relieved,  whilst  perhaps  the  very  best  planned  succours  are  be- 
coming indispensably  necessary. 

99.  If  the  symphysis  pubis  forms  a  crest  projecting  backwards  a 
few  lines,  as  I  have  seen  it  do  in  two  instances,  it  does  not  prevent 
Jthe  delivery  from  being  accomplished  ;  but  during  the  passage  of  the 
head  it  may  contuse  the  bladder  and  the  uterus,  and  favour  the 
laceration  of  these  organs .  Sometimes  one  of  the  acctabula  projects 
into  the  excavation,  or  it  may  be  one  of  the  sciatic  spines,  turned 
very  much  inwards,  that  deforms  the  cavity,  as  was  observed  both 
by  Levret   and  Madame   Lachapellc  ;   exostoses  of  every  sort  an^,i 


40  OF  THE  PELVIS. 

shape  have  been  met  with  ;  scirrhus,  fibrous  tumours,  &c.  iqay  also 
be  developed  so  as  to  interfere  with  parturition  ;  but  it  must  be 
acknowledged  that  a  majority  of  the  faults  of  the  excavation  depend 

upon  too  great  or  too  small  a  curve  of  the  sacrum.  ,. 

-.1. 

§.  III.  Faulty  direction  of  the  axes. 

100.  Nearly  all  these  faults  of  conformation  change,  to  a  greater 
or  less  degree,  the  planes  and  axes  of  the  pelvis.  When  the  sacro- 
vertebral  angle  projects  too  much  towards  the  pubis,  the  hollowness 
of  the  lumbar  region  being  necessarily  augmented,  it  happens  that 
the  angle  between  the  spine  and  sacrum,  instead  of  being  one  hun- 
dred and  thirty-five  degrees,  may  yield  only  one  hundred  and  thirty, 
or  even  one  hundred  and  twenty  degrees  ;  the  axis  of  the  superior 
strait,  therefore,  inclines  forwards,  and  approaches  the  horizontal 
line ;  if  the  coccyx  and  the  point  of  the  sacrum,  restrained  by  the 
sacro-sciatic  ligaments,  are  not  drawn  away  by  this  see-saw,  the 
plane  of  the  inferior  strait  is  depressed  to  the  level,  or  bdowthe 
level  of  the  horizontal  line,  and  may 'even  become  parallel  to  the 
plane  of  the  superior  strait,  which  in  some  measure  justifies  the 
opinion  of  Messrs  Soemmering,  Carus,  Naegele,  &c.,  who  think 
that  even  in  the  natural  state  the  perineal  strait  inclines  downwards 
and  not  upwards.  But  this  disposition,  far  ^m  bringing  the  axis 
of  the  apex  of  the  pelvis  towards  the  perpendicular,  or  from  inclin- 
ing it  backwards,  as  at  the  first  glance  might  be  supposed,  carries  it, 
on  the  contrary,  considerably  in  front,  inasmuch  as  the  anterior  face 
of  the  coccyx  must,  determine  its  direction.  When  the  pubis  rises 
and  the  promontory  becomes  obtuse,  the  axis  of  the  superior  strait 
approaches  towards  the  vei-tical  line,  and  in  some  cases  becomes 
parallel  to  the  axis  of  the  trunk  of  the  body  ;  if,  in  this  case,  the  pos- 
terior wall  of  the  excavation  fails  in  being  sufficiently  concave,  the 
two  pelvic  axes  may  become  parallel,  although  the  plane  of  the  in- 
ferior strait  be  much  inclined  forward.  This  conformation,  which 
especially  favours  the  laceration  of  the  perineum,  gives  risS^'during 
labour,  to  difiiculties  that  have  not  been  sufficiently  dwelt  ^  in  our 
classical  works,  and  to  which  M.  Lobstein  endeavoured  to  direct  the 
attention  of  the  profession  in  1817. 

§.  IV.  Causes  of  deformities  of  the  pelvis. 

101.  In  order  correctly  to  understand  the  causes  of  faulty  con- 
formations of  the  pelvis,  it  is  right  to  study  them  as  they  act  in  in- 
fancy, during  puberty,  or  at  the  adult  age.  Until  the  sixth  or  seventh 
year,  they  are  very  well  explained  by  a  reference  to  rachitis,  which 
is  almost  the  only  causQ  of  them.     The  bones  that  are  chiefly  affected 


OF  THE  PELVIS.  41 

in  this  disease,  being  constantly  pressed  between  two  opposing  forces, 
must  give  way  in  that  direction  in  which  the  strongest  force  operates, 
or  towards  the  point  where  there  is  the  least  resistance. 

102.  Thus,  admitting  that  the  softening  of  the  bones  is  every 
where  equally  great,  that  the  child  is  standing  on  its  feet,  and  rests 
with  the  same  pressure  on  both  legs,  it  is  evident  that  the  base  of 
the  sacrum  will  be  depressed  towards  the  pubis,  and  the  cotyloid 
cavities  will  be  pushed  upwards  towards  the  promontory.  Hence, 
there  will  be  shortening  of  the  sacro-pubic,  as  well  as  of  the  oblique 
diameters:  if  the  child  stands  on  its  feet,  but  leans  more  on  one  foot 
than  on  the  other,  the  oblique  diameter  of  one  side  only  will  be 
contracted  ;  if  he  remains  seated,  the  hollow  of  the  sacrum  will  be- 
come deeper,  while  the  antero-posterior  diameters  of  the  two  straits 
will  be  lessened ;  if  he  be  habitually  laid  upon  his  back,  the  curve 
of  the  sacrum,  instead  of  augmenting,  will  disappear,  as  well  as  the 
pelv-i-vertebral  angle,  and  the  coccy-pubic  diameter  will  generally 
lose  somewhat  of  its  dimensions  ;  a  lateral  posture  will  influence  the 
transverse  diameters,  &.c. 

103.  Although  the  weight  of  the  body  then  will  account  for  most 
of  the  vicious  forms  of  the  pelvis,  it  must,.nevertheless,  be  admitted 
that  their  production  is  in  certain  cases  singularly  favoured  by  the 
active  power  of  the  muscles  that  surround  the  coxo -femoral  articu- 
lation ;  so  much  the  more,  as  the  bones,  most  commonly  softened 
only  at  some  particular  points,  retain  every  where  else  all  the  solidity 
that  is  desirable. 

104.  After  the  first  periods  of  childhood,  the  deformities  of  the 
pelvis  are  almost  always  the  result  of  a  disease,  as  that  malacosteon, 
either  general  or  partial,  which  is  so  common  in  England,  of  osteo- 
malacia, of  irregular  action  of  the  muscles,  and  of  bad  habits  in 
respect  to  attitude.  It  is  thus  that  young  girls,  who,  for  the  purpose 
of  increasing  the  prominence  of  their  hips  and  the  depth  of  the 
lumbar  hollow,  keep  the  pelvis  and  head  thrown  strongly  backwards 
while  they  project  the  abdomen  and  breast  as  far  forwards  as  possi- 
ble, never  think  that  for  the  purpose  of  obtaining  some  elegance  of 
form,  they  run  the  risk  of  being  never  able  to  become  mothers, 
without  exposure  to  the  greatest  danger. 

105.  In  a  diseased  hip  joint  the  head  of  the  femur  has  been  seen 
to  push  the  bottom  of  the  acetabulum  into  the  pelvis,  and  even  to 
pierce  through  the  acetabulum.  Madame  Lachapelle  gives  the  case 
of  a  woman  who  was  affected  with  a  spontaneous  luxation  of  the 
thigh  bone,  and  in  which  the  false  acetabulum  projected  so  far  into 
the  pelvic  excavation  as  to  interfere  with  the  labour ;  the  amputation 
of  a  thigh,  but  not  of  a  leg,  in  an  adult  woman,  and  a  fortiori  in  a 

F 


42  .  OF  THE  PELVIS. 

young  girl,  is  also  capable  of  vitiating  the  pelvis,  and  in  the  following 
manner: — The  artificial  limb,  being  obliged  to  bear  upon  the  ischium, 
the  acetabulum  of  the  sound  side  has  alone  to  support  the  weight  of 
the  body.  Now  the  laws  of  mechanics  teach  us  that  in  this  state  of 
things,  the  oblique  diameter  corresponding  to  the  natural  limb  may 
become  contracted  so  much,  as  to  render  delivery  dangerous,  as  has 
been  proved  by  the  observations  made  by  D'Herbiniaux  and  Madame 
Lachapelle. 

106.  Fractures  and  luxations,  unequally  consolidated,  caries, 
syphilis,  &c.  have  also  sometimes  given  rise  to  obstacles  to  partu- 
rition. To  recapitulate,  it  may  be  said  that  rickets  almost  always 
occasions  deformed  pelvis  in  young  children,  for  at  that  age  the 
members,  of  which  the  coxal  bones  constitute  a  part,  generally  par- 
ticipate in  the  diseased  condition  ;  while  later  in  life,  as  for  example 
at  the  approach  of  puberty,  as  osteo-malacia  almost  solely  affects 
the  spinal  column,  the  curves  of  the  spine  may  be  carried  to  the 
greatest  extent  without  the  pelvis,  in  reality,  suffering  any  change. 
For  further  details  on  this  subject  the  reader  may  consult,  with  ad- 
vantage, the  works  of  M.  Portal,  of  Choulant,  Shaw,  Bamfield,  of 
MM.  La  Chaise,  Pravaz?  &c.  on  spinal  deformity  and  the  diseases 
of  the  spine  and  pelvis. 

§.  V.  Of  the  mensuration  of  the  pelvis. 

107.  When  called  upon  to  ascertain  the  state  of  a  woman's  pel- 
vis, we  ought  to  begin  by  interrogating  the  parents,  or  persons  about 
her,  as  to  the  manner  in  which  her  childhood  had  been  passed ; 
whether  her  first  steps  were  slow  and  difficult,  and  whether  she 
remained  for  a  long  time  weakly  ;  when  we  learn  that  the  joints  had 
been  large  and  as  if  swelled  ;  that  she  had  been  ricketty  or  phthisical, 
we  may  infer  that  rachitis  had  existed,  and  that  her  pelvis  is  pro- 
bably deformed.  We  should  next  examine  very  attentively  the 
other  parts  of  her  body,  and  if  there  be  any  preternatural  curve  in 
the  spine,  if  the  knees  are  large  and  turned  inwards,  if  the  lower 
jaw  projects  too  much  forwards,  if  the  teeth  are  blueish  and  ex- 
hibit transverse  stria?,  the  same  inference  may  be  drawn  ;  while  we 
may  suppose  the  contrary  if  none  of  the  above  circumstances  should 
exist. 

108.  The  theory  of  homologues^  a  theory  which,  as  is  well  known, 
teaches  that  in  animals,  not  only  is  the  right  side  an  exact  repeti- 
tion of  the  left,  but  also  that  the  lower  half  of  the  trunk  repre- 
sents the  superior  half;  that  the  anterior  half  encloses  the  same 
elements  as  the  posterior,  has  very  naturally  given  rise  to  an  idea, 
that  the  pelvis  ought  only  to  be  a  repetition  of  the  head.     In  Ger- 


OF  THE  PELVIS.  43 

many,  therefore,  where  this  doctrine  has  numerous  partisans,  there 
appeared  some  years  since  a  work  in  which  Dr  Weber  endeavoured 
to  demonstrate  that  the  head  and  the  pelvis  are  subject  to  the  same 
laws  of  evolution;  that  the  good  or  bad  conformation  of  one  of  these 
parts  always  corresponds  exactly  with  a  similar  state  of  the  other  ; 
that  the  narrowness  and  depth  of  the  male  pelvis  for  example  are 
in  exact  accordance  with  the  form  of  the  male  head,  whose  vertical 
and  antero-posterior  diameters,  in  general,  exceed  the  transversal, 
while  the  opposite  condition  is  observable  in  the  female,  &c. 

109.  Consequently,  M.  Weber  desires  that  the  inspection  of  the 
head  should  give  us  an  exact  idea  of  the  condition  of  the  pelvis.  His 
method  is  very  simple  :  the  occipito  frontal,  bi-parietal,  and  fronto- 
mastoid  diameters  of  the  head,  exactly  represent  the  sacro-pubic, 
bis-iliac  and  oblique  diameters  of  the  pelvis. 

The  superior  strait  is  proportioned  to  the  cranium,  and  the  face 
is  proportioned  to  the  inferior  strait. 

Although  Mr  Weber  cites  cases  in  support  of  his  system,  I  am 
obliged,  nevertheless,  to  say  that  I  have  seen  the  very  best  shaped 
pelvis  coincide  with  the  most  deformed  crania,  and  vice  versa  ; 
however,  it  has  appeared  to  me  as  it  did  to  Madame  Lachapelle, 
that  the  more  the  upper  part  of  the  face  projects,  the  larger  is  the 
pelvis. 

110.  These  preliminary  researches  being  completed,  we  pass  on 
to  the  examination  of  the  pelvis  itself,  with  all  possible  decency  and 
circumspection.  If  the  woman's  gait  is  easy,  free  and  unconstrained; 
if  the  hips  are  on  the  same  level,  wider  than  the  base  of  the  thorax, 
and  well  rounded,  the  great  trochanters  properly  separated  from 
each  other ;  if  she  is  not  hollow  backed ;  if  the  sacrum  has  neither  too 
much  nor  too  little  convexity;  if  the  symphysis  of  the  pubis  is  neither 
sunk  in  nor  protuberant,  nor  too  long,  there  will  be  some  good  rea- 
son for  reporting  a  good  conformation  ;  by  placing  the  fingers  be- 
tween the  labia  and  the  root  of  the  thighs  we  can  ascertain  whether 
or  not  the  pubic  arch  is  narrovr,  whether  it  forms  a  sufficiently  large 
arc  of  a  circle,  and  whether  the  ischia  are  too  near  each  other. 

111.  It  is  not  necessary,  for  the  purpose  of  correctly  appreciating 
all  these  circumstances,  to  uncover  the  woman,  or  to  make  her  lie 
down  ;  if  there  be  any  fear  of  alarming  her  modesty,  the  examina- 
tion may  be  made  through  her  chemise.  When  all  the  characters 
of  a  good  conformation  are  met  with,  it  is  common  to  dispense  with 
any  farther  examination  ;  but  if  some  of  those  characters  be  want- 
ing, we  should  endeavour  to  determine  the  kind  of  deformity  that 
does  exist :  a  hollow  back,  with  a  very  decided  saliency  of  the  pubis, 
indicates  an  extreme  degree  of  inclination,  and  a  trilobated  form  of 


44  OF  THE  PELVIS. 

the  superior  strait.  If  the  symphysis  be  at  the  same  time  depressed, 
we  may  affirm  that  the  sacro-pubic  diameter  is  shortened,  and  that 
the  strait  is  bilobated,  or  of  the  figure  of  an  oo .  Hips  uneven  or 
too  much  elevated,  and  depressed  external  ihac  fossae  disclose  a 
fault  of  the  bis-iliac  diameter.  The  approximation  of  the  ischia, 
the  convexity  of  the  sacrum,  and  the  forward  inclination  of  the  coc- 
cyx need  only  to  be  hinted  at  to  render  it  easy  even  to  the  least  skil- 
ful person  to  recognise  them  in  an  instant. 

1 12.  As  it  is  essential  to  the  happiness  of  families  that  we  should 
arrive  at  mathematical  results,  and  as  the  employment  of  the  hand 
yields  them  only  in  a  vague  and  approximative  manner,  the  ac- 
coucheurs have  invented  an  infinity  of  instruments  for  the  purpose 
of  exactly  measuring  the  pelvis,  whether  externally  or  internally  ; 
these  instruments  are  called  pelvimeters  or  mecometers. 

113.  Only  two  of  them  can  be  applied  externally  ;  one,  the  (corn- 
pas  d'  epaisseur)  calliper  of  Baudelocque,  which  is  almost  exclu- 
sively employed,  on  account  of  its  simplicity  ;  and  the  other,  the 
mecometer  of  Chaussier,  which  is  scarcely  used  except  at  the 
Maternity  of  Paris.  The  calliper  serves  to  measure,  1.  The  sa- 
cro-pubic diameter,  by  placing  one  of  the  buttons  in  front  of  the 
symphysis  pubis,  and  the  other  on  the  first  spinous  process  of  the 
sacrum ;  2.  The  oblique  diameters,  by  placing  one  of  the  ends  of 
the  calliper  on  the  external  surface  of  the  great  trochanter,  and  the 
other  on  the  projecting  portion  of  the  opposite  sacro-iliac  junction. 
In  the  first  situation,  the  cursor  must  measure  seven  inches;  so  that  by 
deducting  two  inches  and  a  half  for  the  sacrum  and  half  an  inch  for 
the  pubis,  there  may  remain  four  inches  for  the  antero-posterior 
diameter  of  the  superior  strait.  For  the  oblique  diameters,  it  should 
measure  nine  inches,  for  we  must  deduct  two  inches  and  three  quar- 
ters for  the  trochanter,  the  neck  of  the  femur  and  the  acetabulum, 
and  one  inch  and  three-quarters  for  the  postqrior  symphysis. 

114.  Baudelocque  has  asserted  that  the  thickness  of  the  bones 
rarely  varies  more  than  one  or  two  lines  in  the  antero-posterior 
diameter,  and  that  the  results  obtained  by  the  calliper  may  be  relied 
on.  Madame  Lachapelle,  on  the  contrary,  regards  this  mode  of 
proceeding  as  very  deceptive,  and  thinks  the  thickness  of  the  sacrum 
may  vary  from  four  to  five  lines.  Madame  Boivin  goes  still  farther, 
for  she  says  the  thickness  indicated  by  Baudelocque  varies  from  four 
to  twelve  lines.  One  thing  certain  is,  that  leanness  or  fatness  does  not 
diminish  or  increase  in  a  sensible  degree  the  thickness  of  the  soft 
parts,  on  the  points  to  be  touched  by  the  instrument,  and  that  the 
differences  of  thickness  of  the  sacrum  and  pubis   mentioned  by 


Mesdames  Lachapelle  and  Boivin,  are  at  least  extremely  rare. 


OF  THE  PELVIS.  45 

115.  As  to  the  measurement  of  the  oblique  diameters,  the  length 
of  the  neck  of  the  femur  has  appeared  to  v^ry  too  much  to  permit 
practitioners  to  repose  much  confidence  in  it ;  but  I  think,  on  this 
subject  there  has  been  a  very  general  misapprehension  :  for  among 
a  pretty  considerable  number  of  well  formed  pelves  1  have  never 
found  in  this  direction  a  difference  exceeding  a  quarter  of  an  inch, 
more  or  less,  than  the  one  indicated. 

As  the  crista;  of  the  ilia  may  be  considerably  raised  or  much  de- 
pressed, without  the  straits  having  undergone  any  modification,  we 
should  be  exposed  to  too  many  and  too  serious  mistakes,  were  we 
to  take  half  the  distance  between  them  as  the  measure  of  the  bis- 
iliac  diameter.  This  last  is  surrounded  by  too  many  muscles,  and 
moreover  is  of  too  little  importance  for  us  to  measure  it  in  any 
other  way  than  with  the  hand. 

116.  The  fingers  sufiice  for  ascertaining  the  state  of  the  inferior 
strait.  According  to  the  authors,  the  woman  should  be  seated  upon 
the  edge  of  a  chair,  but  she  may  also  be  examined  while  standing 
up.  The  ball  of  the  fore  finger  is  placed  upon  the  point  of  the  coc- 
cyx, and  the  point  of  the  thumb  on  the  edge  of  the  sub-pubic  liga- 
ment, after  which  the  two  fingers,  being  held  at  the  same  distance 
apart,  are  referred  to  a  graduated  scale  to  ascertain  the  degree  of 
separation.  While  the  extremity  of  the  index  is  pressed  against  the 
point  of  the  coccyx,  the  radial  edge  of  the  finger,  instead  of  the  thumb, 
may  be  pressed  against  the  top  of  the  pubic  arch  ;  but  there  is  more 
clanger  in  this  method  of  painfully  pressing  against  the  external  sexual 
organs,  if  their  sensibility  happens  to  be  excited.  To  measure  the 
ischiatic  diameter,  we  must  press  the  points  of  two  fingers  against  the 
lips  of  the  ischia,  at  the  spot  where  the  great  sacroscatic  ligament  is 
inserted,  taking  care  to  push  the  fat  aside  by  gentle  pressure. 

117.  Although  it  is  true  that  this  exterior  exploration  does  not 
enable  us  to  pronounce  with  confidence  as  to  the  nature  and  degree 
of  deformity  of  the  pelvis,  it  is  nevertheless  the  only  one  we  can  have 
recourse  to  in  virgins  ;  in  other  women  it  is  permissible  to  attempt 
the  internal  mensuration,  which  it  has  been  proposed  to  perform  in 
a  great  many  different  ways. 

118.  Coutouly  was  the  first  to  propose  measuring  the  interior 
of  the  pelvis  by  means  of  a  pelvimeter^  which  bears  his  name.  It 
is  impossible  to  convey  a  clearer  idea  of  such  an  instrument,  fre- 
quently modified  by  its  inventor,  than  by  comparing  it  to  the  shoe 
maker's  rule  employed  in  measuring  the  length  of  the  foot.  It  is 
introduced,  closed,  into  the  vagina,  after  which  it  is  opened,  and  one 
of  its  branches  rests  against  the  pubis  while  the  other  is  applied  to 
the  sacro- vertebral  projection.     Now,  the  movable  or  sliding  branch 


46  OF  THE  PELVIS. 

being  graduated  externally,  it  is  easy  to  estimate  the  distance  that 
separates  the  two  vertical  pieces.     In  this  manner  we  can  measure 
the  sacro-pubic  diameter  with  the  most  rigid  exactness  on  the  dried 
pelvis,  but  in  living  women,  Coutouly's  instrument  is  rarely  applicable, 
except  in  the  case  of  pregnancy  ;  it  is  not  so,  however,  in  a  woman 
in  labour,  if  the  summit  of  the  head  be  engaged  in  the  strait ;  besides, 
when  it  can  be  made  use  of,  its  introduction  must  always  be  very 
painful,  and  its  results  will  be  most  generally  fallacious.     This  pel- 
vimeter therefore  deserves   the   neglect  into   which  it  has  sunk. 
Many  accoucheurs  have  endeavoured  to  find  a  substitute,  but  as 
those  they  have  proposed  have  not  fulfilled  the  ends  intended  by  their 
authors  any  better  than  Coutouly's,  they  have  been  quite  as  little 
employed  as  his.     The  thimble  with  which  Asdrubali  armed  the 
fore  finger  in  order  to  increase  its  length ;   the  sort  of  foot-rule, 
in  the  shape  of  a  compass  or  pincers,  with  branches  of  unequal 
lengths,  which  can  be  opened  in  the  pelvis;  those  made  with  the  arms 
straight,  hollow,  or  full  and  graduated,  according  to  the  plans  of 
Stein,  Creve,  and  Aitken,  afford  us  results  not  at  all  more  precise 
than  the  others. 

1 1 0.  The  internal  mensuration  may  be  well  effected  by  the  fingers 
or  hand.    When  the  woman  is  not  in  labour,  or  when  the  head  is  not 
as  yet  engaged,  the  point  of  the  fore  finger  may  readily  be  carried 
to  the  promontory :  the  root  of  the  finger  is  then  raised  up  against 
ihe  arch  of  the  pubis,  and  the  place  where  it  touches  is  marked  with 
a  finger  nail  of  the  other  hand.     Nothing  can  be  easier  after  this 
than  to  ascertain  the  distance  from  pubis  to  sacrum.     Unlike  other 
pelvimeters,  the  finger  is  a  feeling  instrument,  the 'point  of  which 
will  not  slip  away  from  the  promontory  of  the  sacrum  without  the 
operator  knowing  it;  thus  one  of  the  most  frequent  causes  of  error 
is  at  once  obviated.     It  is  true,  that  as  the  line  represented  by  the 
finger  falls  below,  and  not  on  a  level  with  the  top  of  the  symphysis, 
as  it  ought  to  do,  we  commonly  find  the  length  greater  than  it  ought 
in  reality  to  be,  but  by  subtracting  four  or  five  lines  on  account  of 
this  obliquity,  we  shall  have  for  the  remainder  pretty  exactly  the 
measurement  of  the  space  between  the  sacro-vertebral  angle  and 
the  top  of  the  symphysis  pubis.     There  are  two  circumstances,  how- 
ever, that  may  easily  lead  us  into  error.     The  first  is  where  the 
upper  edge  of  the  symphysis  seems  to  have  fallen  backwards ;  and 
the  second,  where  tlie  contrary  obtains.     Here  indeed  the  antero- 
posterior diameter  of  the  superior  strait  might  appear  very  great, 
although  in  fact  it  were  very  small,  and  reciprocally.     But  the  appli- 
cation of  the  calliper  externally  would  readily  correct  the  mistake 
likely  to  arise  from  such  a  disposition  of  the  bones. 


OF  THE  PELVIS.  47 

1 20.  During  labour,  we  can,  if  needful,  pass  the  whole  hand  into  thQi§||pi|i  ||i|| 
vagina  ;  the  thumb  and  forefinger  are  then  separated,  so  as  to  place  i^t 
one  on  the  sacro-vertebral  angle,  and  the  other  behind  the  pubis  ;  J^ 
the  hand  is  withdrawn  in  that  position,  and  we  can,  with  the  assis-  1^ 
tance  of  a  foot-rule,  determine,  within  one  or  two  lines,  the  dimen- 
sions of  the  sacro-pubic  diameter,  without  having  recourse  to  the 

loop  of  thread  proposed  by  Storck,  the  armed  hand  of  Keep,  or  any 
other  of  the  thousand  inventions  for  that  purpose.  Instead  of  using 
the  thumb  and  index  finger,  I  have  sometimes  availed  myself  of  the 
index  and  medius  fingers  passed  high  up  into  the  vagina  ;  after  hav- 
ing separated  them  as  far  as  possible,  and  placed  the  points  of  them 
on  each  extremity  of  the  diameter,  which  it  is  designed  to  measure, 
two  fingers  of  the  other  hand  are  to  be  placed  between  their  roots 
in  order  too  keep  them  apart,  and  then  they  should  be  withdrawn 
from  the  female  organs. 

121.  With  the  finger  we  have  the  advantage  of  appreciating  all 
sorts  of  deformities  of  the  pelvis,  whatever  be  their  seat,  their  nature 
or  degree,  the  straightness  of  the  sacrum,  as  well  as  excess  of  its 
curve;  also,  exostoses  and  tumours  of  whatsoever  nature,  the  trans- 
verse as  well  as  the  antero-posterior  diameters.  By  pressing  with 
a  certain  degree  of  force  against  the  point  of  the  coccyx,  it  is  pos- 
sible even  to  learn  how  much  may  be  gained  in  the  coccy-pubic 
diameter,  by  the  retreat  of  the  coccyx  backwards.  Those  who  have 
objected  that  the  finger  is  not  always  long  enough  to  reach  the  angle 
of  the  sacrum,  have  forgotten  that  a  pelvis,  in  which  the  forefinger 
cannot  reach  to  the  promontory,  is  thereby  proved  to  be  so  spa- 
cious, that  the  accoucheur  need  not  trouble  himself  to*  examine  it 
any  farther.  Moreover,  it  cannot  be  denied  that,  although  it  is  never 
very  difficult  to  discriminate  between  a  deformed  pelvis  and  one  that 
is  not  so,  it  is  nevertheless  impossible,  in  certain  cases,  to  determine 
the  exact  nature  and  degree  of  each  particular  deviation  ;  it  is  there- 
fore no  more  than  right  to  give  the  praise  they  deserve  to  the  efforts 
lately  made  by  Madame  Boivin  to  obtain  more  precise  results  :  the 
instrument  which  she  has  invented,  and  which  she  has  named  intro- 
pelvimeter^  although  founded  on  the  same  principles  as  Coutouly's, 
differs  from  it,  nevertheless,  very  considerably.  As  its  branches  are 
separately  introduced,  one  into  the  rectum,  and  the  other  into  the 
vagina,  and  as  the  curve  of  the  rectal  branch  is  very  deep,  it  may  be 
used  in  the  virgin  as  well  as  in  the  pregnant  woman,  and  at  any 
stage  of  labour  ;  it  may  even  be  employed  in  ascertaining  the  oblique 
and  transverse  diameters,  and  by  altering  its  vaginal  branch  it  could 
easily  be  converted  into  a  calliper.     Nevertheless,  1  doubt  we  shall 


48  OF  THE  PELVIS. 

not  be  able  to  obtain  from  this  apparatus  such  exact  results  as  its  in- 
ventor seems  to  hope  for. 

122.  However  multiplied  -the  means  of  measuring  the  pelvis,  it 
must  have  been  seen  from  the  foregoing,  that  even  the  most  skilful 
accoucheur  will  never  be  able  to  attain  to  the  mathematical  precision 
that  is  desirable  ;  but  is  this  a  reason  for  rejecting  them  entirely,  and 
asserting  with  Puzos  that  the  operation  itself  is  of  no  use  ?  This 
author,  otherwise  so  correct,  has  assuredly  gone  too  far,  in  saying  that 
a  young  woman  ought  to  be  forbidden  to  marry,  if  she  had  ever  been 
affected  with  rickets,  or  if  she  have  a  spinal  deviation,  and  humanity 
and  justice  both  appeal  from  his  judgment.  How  many  ill-shaped 
women  bring  large  robust  children  with  the  greatest  ease  into  the 
world?  Another  serious  inconvenience  might  attach  to  such  a 
general  proscription :  many  women  would  pay  no  respect  to  the 
prohibition,  and  not  be  slow  in  convincing  themselves  that  they  had 
been  frightened  with  dangers  wholly  chimerical.  Hence,  what  al- 
most always  occurs  when  the  effect  does  not  follow  the  threat,  those 
who  run  some  risks  upon  being  married,  and  those  who  run  no  risks 
at  all  would  equally  turn  a  deaf  ear  to  advice.  On  the  other  hand, 
it  would  be  absurd  to  deny  the  importance  of  pelvimetry,  in  labour, 
when  a  decision  must  be  made  between  embryotomy,  and  the  dan- 
gerous operations  that  may  be  performed  upon  the  mother.  Finally, 
by  citing,  for  the  purpose  of  proving  the  uselessness  of  pelvic  men- 
suration, the  cases  of  women  who  were  not  afraid  to  become  preg- 
nant again  after  having  once  undergone  the  Cassarian  operation, 
Puzos  seems  to  me  to  have  misunderstood  their  true  position  :  is  it 
really  the  attraction  of  pleasure  that  always  induces  them  to  yield 
to  the  brutal  husband  that  the  law  has  given  to  them  :  is  it  fair  to 
compare  a  woman  who  fears  above  all  things  to  lose  the  affections 
of  a  man  to  whom  she  is  united  for  life,  to  a  young  girl,  who,  free 
from  all  entanglements,  ought  to  think  first,  and  above  all,  of  her 
own  safety  ? 


ARTICLE  n. 
Of  the  Sexual  Organs. 

123.  In  women  as  in  men,  the  organs  of  reproduction  are  partly 
enclosed  within  the  pelvis,  and  partly  exposed  on  the  exterior  sur- 
face of  that  cavity. 


OF  THE  SEXUAL  ORGANS.  49 

SECTION  1. 
Of  the  External  Parts  of  Generation. 

124.  Under  the  title  of  external  genital  organs  are  generally  com- 
prehended the  mons  Veneris,  the  vulva,  and  the  perineum. 

Merc  appendages  of  the  internal  organs,  these  parts  perform 
only  a  secondary  office  in  the  great  generative  function  ;  but  during 
the  expulsion  of  the  ovum,  they  undergo  changes  and  are  exposed 
to  dangers  which  render  tb^m^t  knowledge  of  them  very  useful 
to  the  physician-accoucheur.! 

§.  I.  Of  the  Mons  VeiWs. 

125.  The  Mount  of  Venus  {the  sur-puhal  eminence,  puhes)  is  a 
sort  of  relief  formed  by  the  soft  parts  that  cover  the  front  of  the 
pubis  ;  it  is  principally  composed  of  fat,  fibrous  filaments,  and  cel- 
lular tissue.  In  fat  women  it  is  sometimes  separated  from  the 
belly  by  a  transverse  groove  of  considerable  depth  ;  the  degree  of 
its  projection  also  varies  on  the  same  account,  but  much  more  on 
account  of  the  projection  of  the  bones  which  support  it  being  dif- 
ferent in  different  subjects. 

126.  The  skin  that  covers  it  is  very  thick,  elastic,  not  very  ex- 
tensible, and  covered  with  hair  in  the  adult ;  it  contains  a  great 
number  of  sebaceous  follicles,  and  the  whole  represents  a  sort  of 
cushion,  the  uses  of  which  are,  according  to  many  authors,  connect- 
ed with  the  business  of  copulation.  The  composition  of  the  mons 
Veneris  very  fully  explains  the  violent  pain  which  accompanies  phleg- 
monous inflammation  of  the  part,  and  enables  us  to  comprehend 
why  abscesses  formed  within  it  should  be  promptly  opened. 

§.  II.  Of  the  Labia  {labia  pudendi  externa). 

1 27.  A  sort  of  cutaneous  folds  which  seem  to  result  put  of  the 
bifurcation  of  the  lower  part  of  the  mons  Veneris,  the  two  labia  sepa- 
rate farther  and  farther  from  each  other,  for  about  half  their  length, 
and  then  approach  to  be  united  again  about  an  inch  in  front  of  the 
anusj  exhibiting  two  commissures,  one  superior  or  pubic,  the  other 
inferior  or  perineal.  Their  external  surface,  formed  by  the  skin  of 
the  thighs,  is,  like  the  pubes,  covered  with  hair,  at  puberty.  Their 
internal  surface  is  smooth,  glabrous,  and  of  a  rose  colour  ;  a  con- 
siderable number  of  sebaceous  or  mucous  follicles  are  observed 
upon  it.  The  accoucheur  ought  to  be  aware  that  the  matter  furnish- 
ed by  these  foUicles  may  become  acrid,  and  irritating  to  such  a 

G 


5Q  OF  THE  SEXUAL  ORGANS. 

degree,  as  to  give  rise  to  a  discharge  that  has  often  been  mistaken 
for  blennorrhagia,  particularly  in  uncleanly  women. 

In  young  girls,  the  thickness  of  the  labia  is  greater  above  than 
below.  In  women  who  have  boriie  children  the  contrary  com- 
monly obtains.  Moreover,  before  the  age  of  puberty,  they  are  very 
close  together,  and  pretty  firm.  After  marriage  they  separate 
from  each  other,  become  flaccid,  bluish,  and  lose  the  regularity  of 
their  form. 

Composed,  like  the  mons  Veneris,  of  filamentous  cellular  tissue  and 
fat,  they  are  also,  like  it,  subject  to  phlegmonous  inflammation,  at- 
tended with  violent  pain,  and  which  ought  to  be  opened  early,  taking 
care  to  plunge  the  instrument  to  q|(ppnsiderable  depth  if  it  is  de- 
sired to  avoid  relapses  and  sinuses.""    ^ 

128.  As  the  tissue  of  which  they  are  composed  is  much  looser 
than  that  of  the  mons,  and  they  are  exposed  to  more  friction,  they 
are  subject  not  only  to  purulent  collections,  but  also  to  bloody  ex- 
travasations, serous  effusions,  &c.  which  may  acquire  a  consider- 
able size. 

129.  The  great  labia  may  also  become  the  seats  of  hernia,  and 
other  tumours,  which  should  not  be  confounded  with  those  above 
mentioned,  '^'he  sht  which  they  circumscribe,  and  which  is  placed 
in  the  direction  of  the  coccy-pubic  diameter,  is  called  the  milva, 
while  the  whole  of  the  external  genitals  is  specially  designated  by 
the  word  pudendum.  This  slit  contains  several  parts,  situated  in 
a  direction  from  above  downwards  : — these  are  the  lesser  labia  and 
the  clitoris,  the  vestibule,  the  meatus  urinarius,  the  vulvar  orifice  of 
the  vagina,  the  hymen,  the  fossa  navicularis,  and  the  fourchette. 

§.  III.     Of  the  lesser  labia  (labia  pudendi  interna). 

130.  Thus  denominated  because  they  are,  in  fact,  much  smaller 
than  the  preceding,  known  also  as  the  nymphcs;  the  lesser  labia  have 
been  compared  to  a  young  cock's  comb.  They  arise,  superiorly, 
by  two  branches,  which  are  continuous  with  the  prepuce  of  the 
clitoris  :  tliey  then  descend,  divergingly,  on  the  inner  face  of  the 
greater  labia,  and  terminate  insensibly  about  the  middle  of  these 
latter,  opposite  to  the  orifice  of  the  vagina.  They  are  of  a  firm 
consistence,  and  a  reddish  colour  ;  they  are  formed  cf  a  tegumen- 
tary  fold  of  a  mucous  chcfracter,  very  delicate  and  very  sensible,  and 
also  of  an  erectile  or  spongy  tissue,  very  closely  resembling  that  of 
the  corpus  cavernosum  in  men. 

131.  At  birth  the  nymphae  generally  protrude  beyond  the  level 
of  the  greater  labia  ;  in  young  virgins,  on  the  contrary,  the  labia  al- 
most entirely  conceal  the  nymphs  ;  and  in  adult  women  who  have 


OF  THE  SEXUAL  ORGANS.  51 

had  children,  the  lesser  labia  again   become  very  salient,  while  they 
lose  their  firmness  and  their  rosy  hue. 

132.  In  this  respect  numerous  varieties  are  to  be  observed  :  some- 
times, indeed,  their  appearance  undergoes  no  alteration  ;  at  other 
times  they  acquire  a  considerable  length,  either  as  regards  their 
whole  extent,  or  only  near  their  posterior  extremity.*'  This  hyper- 
trophy, which  is  in  some  cases  natural,  but  most  commonly  acci- 
dental, is  some  times  carried  to  such  an  extent  as  to  interfere  \*ith 
coition  ;  so  that  it  was  formerly  not  uncommon  to  amputate  the 
nymphs.  In  some  countries  they  are  naturally  much  longer  than 
in  our  European  regions.  In  Persia  and  Turkey,  for  instance,  if 
we  may  believe  the  reports  of  travellers,  it  is  frequently  found 
necessary  to  excise  them. 

133.  From  the  time  of  Kolbe  all  the  naturalists  have  spoken  of  a 
peculiar  fold,  known  as  the  Hottentot  apron^  and  on  which  Tackard, 
Sparman,  Banks,  Peron,  Le  Vaillant,  Lesueur,  and  several  others 
have  emitted  very  different  notions.  Evidently  depending  on  the 
prolongation  of  the  lesser  labia,  as  was  seen  by  Ten  Rhyne,  it  is 
not  among  the  civilized  Hottentot^yhat  it  is  met  with,  but  among  the 
savage  tribes  of  the  environs  of  tM  cape,  discovered  by  the  Dutch, 
who  call  them  Bosgismans  or  Bochismans^  that  is  to  say  Bushmen. 
On  this  subject  no  further  doubt  can  be  entertained,  since  an  indi- 
vidual of  this  species  came  to  be  exhibited  at  Paris,  under  the  title 
of  the  Hottentot  Venus.  In  fact,  the  drawing  of  it  furnished  by 
M.  Flourens,  and  the  descriptions  published  by  MM.  Cuvier  and 
Virey,  show  that,  instead  of  being  three  or  four  lines,  the  nymphte 
of  this  woman  were  several  inches  in  length.  It  is  true,  there  is  a 
wide  difference  between  these  dimensions  and  those  attributed  by 
certain  travellers  to  the  Hottentot  apron ;  but  it  is  easy  to  conceive 
of  an  extent  of  six  or  eight  in  an  organ  which  has  been  seen  actually 
to  measure  three  inches,  provided  if  by  means  resorted  to  in  tiiat 
country  they  are  subjected  to  continual  tractions,  always  increasing 
in  force,  from  childhood  up  to  adult  age. 

134.  The  uses  of  the  nymphae  are  little  known  ;  the  ancients  be- 
lieved that  they  served  to  direct  the  course  of  the  urine,  whence 
tUeir  name  of  nymphaj.  Smellie  and  all  the  writers  who  have  fol- 
lowed him,  pretend  that  they  unfold,  or  disappear  in  labour,  so  as 
to  favour  the  enlargement  of  the  vulva  ;  but  this  assertion  is  wholly 
false  ;  it  is  said,  lastl  What  being  endowed  with  an  exquisite  degree 
of  sensibility,  their  use  is  to  augment  the  pleasure  of  the  veneral  act. 

§.  IV.  Of  the  Clitoris  {coles  feminarum). 

135.  The  clitoris  is  a  tubercle  which  authors  have  compared  to  the 


52  OF  THE  SEXUAL  ORGANS. 

uvula,  and  which  represents,  on  a  small  scale,  the  penis  of  the  male* 
In  the  clitoris  are  distinguishable  a  loose  extremity,  round,  and  of 
an  acorn  shape,  and  a  body  which  is  attached  by  two  roots  to  the 
ischio-pubic  rami ;  but  it  has  not  a  canal  as  is  the  case  in  the  male 
yard.  A  fold  of  skin  covers  it,  serves  as  a  prepuce,  and  then 
proceeds  to  aisappear  in  each  of  the  lesser  labia,  of  which  it  seems 
to  be  the  root. 

136.  During  the  first  months  of  uterine  life  the  clitoris  is  as  long 
and  large  as  the  penis  ;  at  birth  its  dimensions  are  still  considerable. 
But  from  that  time  it  ceases  to  grow,  if  it  does  not  even  diminish, 
so  that  at  the  age  of  puberty  it  is  in  general  not  more  than  four  or 
five  lines  in  length.  There  are,  however,  some  women  in  whom  it 
obtains  a  much  greater  development.  It  has  been  on  some  occa- 
sions seen  to  reach  the  length  of  from  one  to  five  inches;  in  such 
cases  it  scarcely  differs  from  its  analogue  in  the  other  sex. 

137.  Such  a  disposition  as  the  above  is  further  remarkable,  inas- 
much as  it  coincides  wjth  certain  characteristics  which  have  even 
led  to  the  belief  that  individuals  of  such  conformation  belonged  to 
neither  sex  peculiarly  ;  that  is  to  say,  these  women  generally  have 
very  small  breasts,  hard  features^a  beard,  and  a  temper  which  leads 
them  4o  prefer  labour  and  occupations  foreign  to  the  pursuits  of  the 
sex.  They  are  stout  women,  and  are  fond  of  procuring  illicit  en- 
joyments with  persons  of  their  own  sex.  In  a  word,  such  are  the 
individuals  who  have  generally  given  rise  to  the  questions  relative 
to  hermaphrodism. 

138.  Such  is  the  intimate  structure  of  the  clitoris,  that  during 
coition,  the  blood  accumulates  within,  swells  it,  and  occasions  its 
erection;  the  delicate  membrane  that  invests  it  being  of  the  same 
nature  as  that  of  the  nympha?,  and  very  sensitive,  it  has  in  consequence 
been  concluded,  that  with  nymphaj  it  is  the  chief  seat  of  venereal  plea- 
sure. The  clitoris  rarely  exhibits  any  morbid  affections ;  but  as 
its  size,  when  excessive,  may  incommode  during  copulation,  and  as 
its  uses  are  not  very  essential,  it  has  in  several  instances  been  subject- 
ed to  the  operation  of  amputation. 

§.  V.  Of  the  Vestibule. 

139.  Circumscribed  by  the  clitoris,  the  inner  face  of  the  nym- 
ph®, and  the  meatus  urinarius,  the  vestibule  is  a  Small  triangular 
space,  depressed,  corresponding  to  the  uppe^^art  of  thcarch  of  the 
pubis,  through  which  Cclsus  and  M.  Lisfranc  have  recommended 
that  the  bladder  should  be  opened,  for  the  i)urpose  of  extracting  the 
stone  in  females,  and  which  performs  no  special  function  relative  to 
generation. 


OF  THE  SEXUAL  ORGANS.  53 

§.  VI.  Of  the  Urethra. 

140.  Beneath  the  vestibule  is  perceived  the  orifice  of  tlie  urethra; 
this  opening  is  separated  from  the  vagina  only  by  a  kind  of  tubercle, 
which  projects  more  or  less  in  different  persons,  and  which  termi- 
nates its  anterior. middle  column.  On  account  of  this  tubercle,  no- 
thing is  so  easy  as  to  sound  a  woman's  bladder  without  uncovering 
her,  for  after  a  very  little  practice,  the  finger  suffices  for  distinguish- 
ing it  and  guiding  the  sound.  In  women  the  urethra  is  large,  coni- 
cal, about  twelve  or  fifteen  lines  long,  scarcely  curved  ;  it  has  nei- 
ther prostate  gland  nor  bulb  ;  its  lower  wall  may  be  said  to  be  con- 
founded with  the  anterior  wall  of  the  vagina,  and  would  be  rubbed, 
contused,  and  lacerated  much  more  frequently  than  it  is,  were  it 
not  that  it  is  situated  at  the  very  top  of  the  pubic  arch,  in  a  free 
space,  which  is  so  narrow  that  neither  the  occiput  nor  forehead  of 
the  child  can  reach  it  to  lodge  in  it.  Its  natural  direction,  short- 
ness, extensibility,  and  width,  readily  explain  the  ease  with  which  the 
catheter  is  introduced,  the  rare  occurrence  of  urinary  calculi  in 
women,  and  the  fact  that  even  fecundation  has  sometimes  taken 
place  where  the  womb  opened  only  into  the  bladder. 

141.  The  orifice  of  the  vagina^  irregular,  and  of  greater  or  less 
size  ip  women  who  have  borne  children,  more  rounded,  but  of 
equally  variable  dimensions  in  married  women  who  have  never  yet 
become  mothers,  is  in  virgins  contracted  by  the  hymen. 

* 
§.  VII.  Of  the  Hymen  {valvula  vaginalis). 

142.  Admitted  by  some  and  rejected  by  others  during  the  seven- 
teenth and  eighteenth  centuries,  the  hymen,  and  not  |the  mem- 
brane of  the  hymen,  as  it  is  denominated  in  several  French  works,  is  a 
fold  which  always  exists,  provided  it  have  not  been  destroyed,  in  young 
girls.  In  shape  resembling  a  half  moon  with  its  concave  and  sharp 
edge  turned  forwards,  its  extremities  are  sometimes  so  much  pro- 
longed as  to  unite  under  the  urethra,  and  thus  form  a  circular  valve, 
whose  breadth,  however,  diminishes  as  it  approaches  the  meatus 
urinarius :  being  on  its  convex  edge  continuous  with  the  mucous 
membrane  of  the  vagina  and  vulva,  the  hymen  m&y  contract  the  en- 
trance of  the  vulvo-uterine  canal  in  very  various  degrees,  and  even 
close  it  entirely.  Its  circle  always  contracts  from  behind  forwards. 
I  have  sometimes  detected  muscular  fibres  in  it,  which  were  arranged 
in  a  decussating  manner  as  in  the  womb ;  in  such  cases,  it  was 
thick,  strong,  elastic,  and  very  much  developed  ;  at  other  times  I 
have  seen  it  thin,  transparent  as  a  pellicle,  and  very  easily  broken  ; 
in  general  it  is  thicker  at  birth  than  at  any  otlier  period  of  life.     In 


54  OF  THE  SEXUAL  ORGANS. 

new  born  infants  it  often  presents  th*e  shape,  the  rosy  tint,  and  soft- 
ness of  the  lesser  labia. 

143.  Regarded  as  the  seal  of  virginity  by  the  vulgar,  and  for  a 
long  time  so  considered  by  medico-jurists  and  magistrates,  the  hymen 
has  on  more  than  one  occasion  been  the  cause  of  an  iniquitous  de- 
cision by  .the  tribunals,  either  in  condemning  an  innocent  woman,  or 
on  the  contrary,  in  absolving  one  who  was  scandalously  guilty.    But 
at  present  it  is  universally  admitted  that  a  thousand  causes  foreign 
to  the  act  of  coition  may  destroy  it,  and  that  copulation  itself  does 
not  always  occasion  its  rupture.     If  this  membrane  be  thin,  delicate 
and  broad,  a  sudden  or  extensive  movement  of  the  limbs,  excoria- 
tions, the  appearance  of  the  menses,  &c.,  may  cause  it  to  disappear. 
If  it  be  thick,  muscular,  elastic,  but  narrow,  the  sexual  union  would 
not  be  prevented,  and  the  hymen  might  remain  whole  until  labour 
should  take  place,  as  is  proved  by  the  cases  mentioned  by  Pare, 
Nffigele  and  others  ;  but  I  beheve  it  incapable  in  any  case  of  furnish- 
ing a  real  obstacle  to  the  escape  of  the  child.     If  the  hymen  be  broad 
and  resisting,  while  at  the  same  time  it  either  partially  or  completely 
closes  the  canal  of  the  vagina,  it  might  form  an  insurmountable  ob- 
stacle to  the  flow  of  the  menses  outwards,  and  by  retaining  the 
blood  in  the  vagina  or  womb,  give  rise  to  symptoms  that  would  be 
more  or  less  important,  according  to  circumstances.     Smellie,  Den- 
man,  &c.,  report  the  cases  of  women  in  whom  this  state  of  things 
produced  all  the  general  symptoms  of  pregnancy,  and. who  reco- 
vered their  ordinary  health  as  soon  as  an  incision  into  the  hymen 
had  allowed  of  the  escape   of  the  blood  with  which  the  parts 
were  filled.     I  have  been  consulted  on  account  of  one  young  lady 
twenty-two  years  of  age,  whose  hymen  had .  prevented  the  consum- 
mation of  marriage.     I  met  with  another  specimen,  in  the  corpse 
of  a  woman  about  forty  years  of  age,  who  had  cohabited  with  her 
husband  for  a  long  time,  but  without  having  any  children.     As  a 
general  rule,  however,  the  hymen  is  ruptured  at  the  first  sexual  ap- 
proach, wjiich  in  consequence  of  this  laceration  is  accompanied  with 
more  or  less  jAin,  and  a  slight  discharge  of  blood.     When  once 
torn,  its  shreds  contract,  and  give  rise  to  one  or  more  tubercles, 
known  by  the  name  of  myrtiform  caruncles. 

§.  VIII.  Of  the  Myrtiform  or  Vaginal  Caruncles. 

144.  There  arc  still  a  great  many  physiologists  who  think  that  the 
myrtiform  caruncles  arc  special  organs,  and  independent  of  the  hy- 
men; they  found  their  opinion  on  the  circumstance  that  they  are 
sometimes  found  even  where  the  hymen  is  whole,  and  that  their 
number  and  situation  do  not  appear  to  be  accounted  for  on  any  other 


OF  THE  SEXUAL  ORGANS.  55 

hypothesis.  The  opposite  opinion  tends,  it  is  true,  to  predominate ; 
but  as  its  supporters  have  not  refuted  their  antagonists  so  convin- 
cingly as  to  dissipate  all  doubts  on  the  subject,  I  have  sought  for  the 
cause  of  such  a  discrepancy  of  sentiment,  and  believe  I  have  disco- 
vered it.  Of  the  four  caruncles  commonly  observed  at  the  entrance 
of  the  vulvo- uterine  canal,  and  which  correspond  to  the  four  extre- 
mities of  the  vertical  and  transversQ^ameters  of  this  opening,  two, 
namely,  that  which  is  near  the  meflos  urinarius,  and  that  which  is 
near  the  fourchette,  belong  to  the  mimle  columns  of  the  vagina, 
while  the  other  two  only  are  the  remains  of  the  hymen.  The  for- 
mer, therefore,  exist  even  in  virgins,  while  the  latter  ought  only  to 
be  met  with  after  coition.  It  is  clear,  moreover,  that  these  latter, 
or  the  lateral  caruncles,  may  vary  in  number,  size  and  situation, 
accordingly  as  the  hymen  is  broken  into  two,  three,  or  four  shreds, 
of  equal  or  unequal  sizes,  in  this  or  that  direction,  and  according  as 
the  hymen  itself  was  of  greater  or  less  thickness  and  breadth  ;  these 
latter  caruncles  are  altered  in  form,  and  sometimes  disappear  entirely 
in  consequence  of  labour,  while,  on  the  other  hand,  the  median  car- 
uncles enlarge,  rather  than  diminish  with  the  progress  of  age. 

§.  IX.  Perineum,  fossa  navicularis,  fourchette,  froenura,  commis- 
sure. 

145.  Between  the  perineal  commissure  of  the  vulva,  or  greater 
labia,  and  the  convex  edge  of  the  hymen,  or  posterior  semi-cir- 
cumference of  the  outer  orifice  of  the  vagina,  is  seen  the  fossa 
navicularis ;  the  fourchette  or  the  frcenum  forms  its  anterior  edge, 
and  ought  not  to  be  confounded  with  its  posterior  edge,  which 
is  the  commissure  itself.  It  most  commonly  happens  that  the 
fourchette  is  torn  in  a  first  labour,  and  the  fossa  navicularis  is  there- 
by forever  destroyed. 

146.  The  perineum,  which  separates  the  vulva  from  the  anus,  is 
scarcely  an  inch,  or  an  inch  and  a  half  in  length ;  its  inferior  surface 
is  composed  of  skin  ;  it  happens,  but  rarely,  that  it  is  covered  with 
hairs,  which,  if  they  be  cut  ofi",  produce,  while  growing  again,  the 
effect  of  a  brush,  and  sometimes  occasion  intolerable  pain,  the 
cause  of  which  it  is  well  to  understand.  Above,  that  is,  between 
the  skin  and  the  point  where  the  rectum  and  vagina  come  into  im- 
mediate contact,  there  is  a  triangular  space  filled  with  fleshy  fibres, 
cellular  tissue,  fat,  nerves  and  vessels,  and  which,  constituting  a  part 
of  the  perineum,  allow  it  to  elongate  itself  very  considerably  during 
labour ;  to  such  a  degree,  indeed,  as  will  be  seen  in  the  sequel,  that 
from  being  only  an  inch  long,  as  in  its  natural  state,  it  may  be  extended 


56  OF  THE  SEXUAL  ORGANS. 

even  to  four  or  five  inches  in  length,' when  most  strongly  pressed 
upon  by  the  head. 

147.  Without  repeating  on  this  occasion  what  I  have  elsewhere 
said,  of  the  arrangement  of  the  parts  that  compose  the' female  peri- 
neum, I  think  it  may  be,  nevertheless,  useful  to  recal  to  mind  the 
mean  dimensions,  which,  after  a  great  number  of  observations,  I 
have  been  enabled  to  establish  ugrelation  to  the  various  objects  which 
I  have  now  examined.  W 

It  is  found : 

1.  That  from  the  upper  part  of  the  pubis  to  the  clitoris  is  two 
inches  and  a  half. 

2.  From  the  anterior  commissure  of  the  vulva  to  the  anus,  three 
inches  and  a  half. 

3.  From  the  clitoris  to  the  posterior  commissure  of  the  vulva,  one 
inch  and  a  half. 

4.  From  the  posterior  commissure  of  the  vulva  to  the  point  of  the 
coccyx,  three  inches. 

5.  From  the  coccyx  to  the  anus,  about  eighteen  lines. 

6.  From  the  anus  to  the  vulva,  fifteen  lines,  allowing  only  a  Cew 
lines  besides  for  the  orifice  of  the  rectum. 

It  is  also  useful  to  know  that  the  constrictor  vaginfe  muscle, 
which  is  analogous  to  the  accelerator  urinas  of  the  male,  is  inclosed 
within  the  body  of  the  greater  labia,  and  that  it  is  so  strong  in  some 
mdividuals,  as  to  contract  with  energy  during  coition,  and  consider- 
ably lessen  the  size  of  the  orifice  of  the  vagina ;  that  the  only  im- 
portant artery  in  the  neighbourhood  of  these  parts,  the  pudic  artery, 
is  confined  as  it  were  entirely  towards  the  circumference  of  the 
perineal  strait,  and  consequently,  that  it  is  not  on  account  of  he- 
morrhage that  lacerations  of  this  region  are  likely  to  prove  dan- 
gerous. 

§.  X.  Difierence  between  the  external  organs  of  generation  of 
women,  and  those  of  brutes. 

148.  In  reviewing  the  principal  zoological  classes,  it  is  easy  to 
perceive  that  the  external  sexual  parts,  mere  organs  of  coition,  as 
m  the  human  species,  arc  far  from  exhibiting  the  same  characters, 
and  the  same  completeness  in  all  cases. 

In  fishes,  reptiles  and  birds,  the  cloaca  supplies  their  place,  ex- 
cept m  some  .species  that  have  a  clitoris  ;  in  the  mammifcrai,  the 
hcvizontal  posture  renders  a  mona  Veneris  useless,  and  accordingly, 
not  a  trace  of  it  is  tu  be  found. 

According  to  M.  Cuviur,  neither  do  the  nymphje  exist  in  any 


OF  THE  SEXUAL  ORGANS.  57 

fiimily  ;  however  I  have  reason  to  think  I  observed  it  in  the  giraffe 
which  is  now  in  the  Jardin  du  lloi. 

149.  The  vulva  and  greater  labia  are  met  with  in  all  classes,  but 
with  very  various  forms.  The  interior  is  almost  always  wrinkled, 
as  in  the  cow,  the  tiger,  &c.  Placed  lengthwise  in  the  majority  of 
animals,  it  is  in  some  cases  transverse  as  in  the  hyena,  or  circular 
as  in  the  rabbit  and  in  most  of  the  rodentia  ;  very  shallow  as  in 
women  ;  it  forms  in  the  guinea  pig  a  canal  as  long  as,  or  even  longer 
than  the  vagina  of  the  bear  and  some  species  of  the  monkey  ;  all  of 
them  have  a  clitoris,  which  in  some  is  very  small,  and  very  large  in 
others,  the  monkey  for  example,  where  it  is  connected  as  to  size  with 
an  excessively  lascivious  disposition.  The  hymen ,  attributed  by  most 
authors  to  woman  alone,  is  certainly  to  be  found  in  a  great  number 
of  animals.  Is  the  plait  or  circle  that  separates  the  vagina  from 
the  vulva  in  the  she  goat,  the  ewe,  and  the  bitch  any  thing  else  ? 
M.  Cuvier  has  noticed  it  in  the  hyena  and  the  daman.  It  is  im- 
possible to  mistake  it  in  the  semi-lunar  membrane  which  contracts 
the  vagina  of  the  virgin  mare  and  she  ass,  or  in  that  which  was  no- 
ticed by  Steller  in  the  lamantin  of  the  north  :  I  think  the  giraffe  has 
it  also.  The  greater  labia,  the  clitoris,  and  the  hymen  are  there- 
fore the  most  constantly  met  with  of  all  the  external  organs  of 
generation  ;  and  in  all  the  species,  these  parts  of  coition  are,  there- 
fore, rather  destined  to  augment  the  pleasure  of  the  venereal  con- 
gress than  to  play  any  fundamental  part  in  the  great  act  of  repro- 
duction. 

§.  XI.  Anomaly  of  the  external  organs  of  generation. 

160.  I  have  already  spoken  of  the  preternatural  development 
of  the  clitoris  and  nymphae,  as  well  as  the  extreme  length  of  these 
parts  among  certain  nations  ;  I  have  now  to  remark,  that  the  greater 
labia  have  been  in  some  instances  found  wholly  wanting,  in  conse- 
quence of  malformation  of  the  individual ;  sometimes  they  adhere 
to  each  other,  either  at  one  spot  or  throughout  their  whole  extent, 
as  in  the  three  examples  cited  by  Madame  Boivin,  as  was  seen  by 
Cassan  and  M.  Willaume,  who  saw  one  case  each,  and  as  is  fre- 
quently met  with  in  Persia,  Egypt,  Turkey,  and  throughout  almost 
the  whole  of  Africa,  where  the  barbarous  custom  of  infibulation  is 
still  practised.  Borelli  says  he  saw,  in  the  hospital  of  Castro,  a  little 
girl  who  had  two  vulvas,  one  above  the  other.  It  might  also  be 
said  that  where  the  vagina  is  completely  double,  there  are  two 
lateral  vulvas.  The  same  anomalies  are  found  to  occur  in  the 
nymphae,  which  Neubauer  in  one  case  found  to  be  triple,  and  which 
H 


58  OF  THE  SEXUAL  ORGANS. 

depend,  too,  more  frequently  on  an  acquired  disease  than  on  a  pri- 
mitive fault  of  the  conformation. 


SECTION  11. 
Internal  Genital  Organs. 


.My 


The  internal  parts  of  generation  in  women  consist  of  the  womb, 
the  vagina,  the  fallopian  tubes,  the  ovaries,  and  the  ligamentous  at- 
tachments. 

§.  I.  Of  the  Uterus  {matrix). 

151.  The  uterus  or  womb  is  a  hollow  muscle,  destined  to  lodge 
and  nourish  the  ovum  during  pregnancy,  and  expel  it  by  the  process 
of  labour.  It  is  therefore  essentially  the  organ  of  gestation,  and  not 
of  generation,  as  has  been  erroneously  repeated  by  several  authors. 

152.  Situation.  Situated  in  the  pelvic  excavation,  behind  the 
bladder,  in  front  of  the  rectum,  beneath  the  sma^ll  intestines,  and 
continuous  below  with  the  vagina,  the  uterus,  in  its  unimpregnated 
state,  is  generally  placed  in  the  direction  of  the  axis  of  the  superior 
strait. 

153.  Configuration.  Its  shape  is  that  of  a  pear  or  a  small  flat- 
tened gourd,  or  further,  of  a  truncated  cone,  compressed  antero-pos- 
teriorly,  its  base  being  turned  upwards,  its  apex  downwards. 

154.  Division.  For  the  purpose  of  explaining  the  phenomena  of 
pregnancy,  the  womb  is  divided  into  fundus,  body,  and  neck.     The 

fundus  comprises  all  that  portion  that  is  found  above  a  horizontal 
line  drawn  from  one  fallopian  tube  to  the  other ;  the  body  extends 
from  this  same  line  to  the  contracted  portion  which  marks  the  com- 
mencement of  the  neck  ;  and  the  latter,  more  or  less  swelled,  con- 
stitutes the  lower  portion  of  the  organ. 

A.  External  Surface. 
165.  The  external  surface  of  the  womb  has  been  divided  into,  1. 
An  anterior  region,  which  is  slightly  convex,  its  upper  half  being 
covered  with  peritoneum,  and  the  remainder  being  in  contact  with 
the  basfond  of  the  bladder  ;  2.  A  posterior  region.,  much  more  convex 
than  the  preceding,  covered  in  its  whole  extent  with  peritoneum, 
and  separated  from  the  rectum  by  a  space  or  chink  in  which  the 
intestines  may  become  strangulated  ;  3.  Three  edges,  one  of  which, 
superior,  convex,  and  smooth,  corresponds  to  tlic  fundus,  and  two 
others,  lateral,  convex  on  their  superior  half,  and  concave  be- 
low, are  lost,  as  it  were,  in  the  broad  ligaments;  4.  Three  angles. 


OF  THE  SEXUAL  ORGANS.  59 

the  two  first,  superior  and  lateral,  unite  the  three  edges,  and  seem  to 
give  origin  to  the  tubes,  the  ligaments  of  the  ovaries,  and  the  round 
ligaments  ;  the  third,  inferior,  far  more  important  than  the  others, 
is  seen  in  the  upper  part  of  the  vagina,  and  deserves  very  special 
attention. 

It  exhibits  an  orifice  resembling  a  transverse  slit,  dividing  it  into 
two  lips,  and  has  received  the  name  of  the  tenches  mouth  (ostinctE). 
Of  these  two  lips,  the  anterior.^  which  is  thicker  and  broader  than 
the  posterior,  is  also,  indeed,  somewhat  the  longest.  Nevertheless, 
as  the  vagina  ascends  higher  behind  than  in  front,  it  seems  when  a 
woman  is  carefully  touched,  that  the  posterior  is  longer  than  the 
anterior  lip.  To  this  peculiarity,  doubtless,  ought  to  be  attributed 
the  error  into  which  many  accoucheurs  have  fallen,  who,  not  con- 
tent with  asserting  that  the  anterior  lip  is  the  shortest,  have  also 
represented  it  as  being  the  thinnest  in  drawings  which  in  other  re- 
spects were  most  carefully  made.  To  convince  any  one  of  the  pro- 
portional length  of  the  two  lips  of  the  neck,  it  is  only  necessary  to 
separate  the  womb  from  the  vagina  in  the  dead  subject.  It  will 
then  be  seen  that  the  posterior  lip  is  at  the  same  time  the  thinnest, 
the  narrowest,  and  the  shortest.  However,  this  difference  is  not 
to  be  seen,  except  in  women  who  have  borne  children.  In  virgins 
the  lips  are  very  near  to  each  other,  and  we  can  scarcely  feel 
with  the  finger  the  line-like  slit  that  separates  them  ;  but  it  may  be 
distinguished,  as  has  been  judiciously  remarked  by  M.  Dubois,  by 
comparing  the  sensation  produced  by  touching  it,  to  that  experi- 
enced by  touching  the  point  of  the  nose  with  the  end  of  a  finger. 
Sometimes,  however,  instead  of  such  a  narrow  slit,  we  meet  with  a 
circular  orifice  ;  a  modern  author  has  even  taken  occasion  from  this 
circumstance,  to  advance  the  opinion,  that  such  is  the  natural  ar- 
rangement of  the  part :  but  this  is  evidently  an  error.  M.  Desor- 
meaux  thinks  that  this  last  mentioned  form  is  particularly  to  be  met 
with  in  women  who  are  not  apt  for  fecundation ;  but  this  is  an  opi- 
nion which  requires  to  be  supported  by  additional  evidence.  Be- 
sides, we  must  take  care  not  to  confound  this  circular  form  with 
that  which  is  pretty  often  observed  at  a  certain  stage  of  pregnancy, 
in  women  who  have  borne  children  before  ;  which  it  is  not  always 
an  easy  matter,  however,  to  avoid. 

156.  Before  women  become  mothers,  the  lips  of  the  os  tineas 
are  smooth,  regular  and  pretty  firm,  although  supple  ;  the  whole  neck 
terminates  in  an  extremity  which  is  rather  acuminated  than  bulging. 
After  one  or  two  confinements,  its  slit  is  wider,  more  uneven  ;  the 
free  extremities  of  the  lips  are  farther  apart ;  the  anterior  is  elon- 
gated, often  ends  in  a  point,  and  exhibits  tubercles  or  bumps,  which 


60  OF  THE  SEXUAL  ORGANS. 

are  also  found  on  the  posterior  lip,  and  separated  from  each  other 
by  crevices  of  greater  or  less  depth,  and  in  greater  or  less  number, 
chiefly  in  the  left.  It  is  true,  however,  that  this  last  nnentioned  dis- 
position does  not  demonstrate  with  mathematical  certainty  that  there 
have  been  several  pregnancies,  for  it  may  be  occasioned  by  disease. 
It  should  also  be  understood,  that  the  contrary  state  persists  in  some 
women,  after  a  great  many  lyings  in.  Thus,  in  a  woman  in  her 
seventh  pregnancy,  I  have  seen  the  vaginal  angle  of  the  womb  more 
regular  than  in  another  whom  I  examined  by  way  of  comparison,  and 
who  was  in  her  first  pregnancy  :  but  in  this,  as  in  every  thing  else, 
we  should  remember  the  rule  without  forgetting  the  exceptions. 

B.  Interiial  Surface. 

157.  The  wonnb  presents  an  internal  surface,  which  is  also  called 
its  cavity,  and  which  the  accoucheurs  divide  into  superior  portion  or 
cavity  of  the  body,  and  inferior  portion  or  cavity  of  the  neck. 

168.  Cavity  of  the  body.  The  first,  of  a  triangular  shape,  with 
sides  separated  from  each  other  only  by  a  layer  of  mucus  which  is 
more  or  less  thick,  sometimes  exhibits,  on  the  median  line,  a  sort  of 
raphe  or  crest,  which  runs  through  its  whole  length,  and  is  joined 
by  other  oblique  or  transverse  lines.  The  sides  of  this  cavity,  as 
well  as  its  bottom,  are  almost  straight,  sometimes  slightly  convex  in 
young  girls,  while  they  generally  remain  pretty  concave  after  a 
lying-in.  Its  two  superior  angles  are  continuous  with  the  origin  of 
the  fallopian  tubes,  which  are  sometimes  expanded  like  a  funnel,  and 
ought,  according  to  M.  Geoffi-oi  St  Hilaire,  to  be  regarded  as  the 
rudiment  of  the  aduterum,  which  is  remarked  in  most  of  tlic  mam- 
mifera3 ;  its  inferior  angle  is  called  the  superior,  uterine  or  internal 
orifice  of  the  neck,  and  is  the  point  by  which  the  two  cavities  of  the 
womb  communicate  with  each  other. 

169.  Cavity  of  the  neck.  The  cavity  of  the  neck,  of  an  oval 
shape,  is  twelve  or  fifteen  lines  in  length,  and  five  or  six  lines  in 
width  at  its  widest  part,  and  one  or  two  lines  from  front  to  rear. 
On  its  two  walls,  and  particularly  on  the  posterior  one,  are  found 
certain  plaits  or  lines,  which  have  been  carefully  studied  of  late  by 
Madame  Boivin.  This  is  a  sort  of  gathering,  which  seems  to  be  only 
a  continuation  of  that  which  is  found  in  the  womb  itself,  but  much 
more  developed.  The  median  crest,  the  largest  of  all,  more  salient 
in  the  middle  than  at  either  end,  is  formed,  as  it  were,  by  the  approxi- 
mation of  many  small  secondary  folds  crowded  together.  The  trans- 
verse lines  are  all  oblique  from  above  downwards,  and  from  the 
aides  inwards,  towards  the  preceding  line,  on  which  they  terminate. 


OF  THE  SEXUAL  ORGANS.  61 

Tike  the  barbs  of  a  feather,  on  their  stem.  SUghtly  concave  upwards, 
they  leave  pretty  deep  grooves  between  each  other,  in  which  a  good 
many  mucous  folHcles  are  to  be  found,  and  occasionally,  some  small 
round  transparent  vesicles,  a  sort  of  hydatids,  formerly  regarded  as 
germs,  and  for  a  long  time  known  as  the  eggs  of  Naboth.  More 
deeply  seated,  that  is,  beneath  this  network,  which  constitutes  what 
is  called  the  arhor  viicB.  there  is  another  one,  somewhat  differently 
disposed,  but  which  cannot  be  examined  until  we  come  to  speak  of 
the  structure  of  the  organ.  At  the  place  where  the  two  walls  of 
the  neck  unite,  and  where  the  transverse  lines  too  are  confounded, 
are  also  seen  two  longitudinal  lines. 

160.  The  superior  opening  of  the  neck  having  been  above  indi- 
cated as  the  uterine  orifice,  it  is  useless  to  return  again  to  the  consi- 
deration of  it.  The  inferior  orifice  divides  the  lips  of  the  os  tineas 
from  each  other  ;  and  as  it  opens  into  the  vagina,  it  may  very  pro- 
perly be  called  the  vaginal  orifice  of  the  womb.  From  what  has 
been  said,  and  which  ought  to  be  understood  of  the  cervix  of  a  young 
woman,  previously  to  being  fecundated,  it  is  evident  that  the  inferior 
angle  of  the  uterus  ought  to  be  quite  acute,  that  a  little  higher  up 
the  size  of  the  neck  should  be  greater,  and  that  this  part  ought  to 
be  again  contracted,  and  as  it  were,  strangulated  at  the  place  where 
it  unites  with  the  body  of  the  organ. 

C.  Dimensions  of  the  Womb. 

161.  In  women  who  have  never  had  children,  the  womb,  measured 
from  the  most  salient  point  of  the  fundus  to  the  end  of  the  anterior 
lip  of  the  neck,  I  have  found  to  be  of  an  average  length  of  from 
twenty-six  to  twenty-eight  lines  ;  from  one  fallopian  tube  to  the  other, 
from  seventeen  to  twenty  lines  ;  from  front  to  rear,  in  the  thickest 
part,  nine  to  eleven  lines  ;  at  the  neck  I  have  found  that  there  were, 
transversely,  ten  to  twelve  lines,  five  or  six  lines  from  front  to  rear, 
eight  or  ten  lines  across  at  the  place  where  it  is  strangulated,  and 
that  there  were  four  lines  of  thickness  at  the  same  point.  The  pa- 
rietes  of  the  womb  are  four  lines  in  thickness  at  the  body,  and  two 
or  three  at  the  neck  ;  the  lips  project  two  or  three  lines  into  the 
vagina,  and  the  slit  that  separates  them  is  of  about  the  same  extent. 

162.  After  several  pregnancies  the  uterus  is  from  two  and  a  half 
to  three  inches  in  its  entire  length  ;  twenty  to  twenty-four  lines  wide 
at  the  fundus,  fifteen  to  sixteen  at  the  widest  part  of  the  cervix, 
twelve  to  fourteen  lines  thick  at  the  body,  eight  to  ten  at  the  neck, 
and  each  of  the  walls  are  six  lines  in  thickness  :  the  vaginal  orifice 
is  half  as  large  again  as  in  a  virgin. 

In  the  first  named  state,  the  womb  weighs  from  eight  to  twelve 


52  OF  THE  SEXUAL  ORGANS. 

drachms,  and  in  the  second  about  two  ounces.  It  will  be  seen  that 
these  dimensions  are  very  near  those  given  by  Rcederer  ;  and  they 
are  the  results  of  a  considerable  number  of  measurements  taken  on 
the  dead  subject. 

D.  Structure. 

163.  An  external  membrane,  an  internal  membrane,  a  peculiar 
tissue,  numerous  vessels,  nerves  and  cellular  tissue  enter  into  the 
composition  of  the  womb. 

164.  a.  The  external  membrane^  of  a  serous  character,  belongs 
to  the  peritoneum  ;  posteriorly,  it  descends  lower  than  the  cervix,  on 
to  the  posterior  surface  of  the  vagina,  while,  in  front,  it  is  reflected 
upon  the  bladder  after  having  invested  the  anterior  surface  of  the  body 
of  the  uterus,  and  before  it  reaches  the  cervix.  Very  closely  adhe- 
rent along  the  upper  edge  and  median  line  of  the  uterus,  it  becomes 
less  so  nearer  the  sides,  and  in  the  neighbourhood  of  the  broad  liga- 
ments maybe  easily  detached.  Observers  have  not  agreed  in  rela- 
tion to  its  thickness,  doubtless  because  it  has  often  been  confounded 
with  the  layer  immediately  beneath  it,  but  which  in  reality  ought  to 
be  distinguished  from  it.     On  the  whole,  it  is  thin  and  very  dense. 

166.  Sub-peritoneal  layer.  This  is  kind  of  doubling  which  gives  to 
the  peritoneal  layer  a  borrowed  thickness,  covers  every  part  of  the 
uterus,  extends  itself  into  the  broad  ligaments,  and  is,  indeed,  only 
a  portion  of  the  common  sub-peritoneal  fascia,  which  at  this  point 
assumes  most  of  the  characters  of  the  yellow  fibrous  tissue  ;  that  is 
to  say,  it  is  elastic,  strong,  dense,  and  may  be  converted  into  real 
muscular  tissue,  as  has  been  remarked  by  Madame  Boivin,  and  as  I 
have  several  times  observed  myself. 

166.  b.  The  existence  of  the  internal  membrane  is  not  admitted 
by  all  anatomists.  Gordon,  Chaussicr,  M.  Ribes,  &c.  reject  it ; 
the  most  careful  dissections,  putrefaction,  ebullition,  chemical  re- 
agents, have  all  failed  in  demonstrating  its  existence  to  these  observers, 
except  towards  the  close  of  pregnancy ;  but  at  that  period  it  con- 
stitutes, according  to  them,  a  pellicle  of  new  formation,  and  not  a 
natural  membrane.  Beclard  also  taught  that  the  internal  membrane 
of  the  uterus  is  not  a  complete  mucous  membrane,  and  that  it  has  no 
epithelium.  It  is  true,  that  except  during  pregnancy,  we  cannot 
always  demonstrate  the  existence  of  an  uterine  raucous  membrane, 
but  in  several  women  who  died  while  pregnant,  or  shortly  after  deli- 
very, I  have  succeeded  in  raising  very  distinct  portions  of  it.  But 
even  could  we  not  succeed  in  separating  it  mechanically,  analogy 
would  suflice  to  convince  us  of  its  ptesencc  :  the  mucous  membranes 
are  exclusively  provided  witli  villi ;  they  alone  furnish  mucus  in  the 


OF  THE  SEXUAL  ORGANS.  63 

healthy  state,  and  muco-purulent  matters  in  a  state  of  disease  ;  it  is 
on  their  surfaces  that  we  meet  with  polypi  and  sanguine  exhalations. 
Hence,  the  glairy  discharge  that  occurs  during  labour,  the  leucor- 
rhceal  discharges,  the  menstrual  function,  &,c.  all  prove  that  the 
inner  surface  of  the  womb  performs  the  same  functions  and  is  sub- 
ject to  the  same  diseases  as  the  mucous  membranes.  I  conclude, 
therefore,  that,  if  we  can  in  reality  refuse  to  admit  the  existence  of  a 
membrane,  we  shall  at  least  be  forced  to  admit  that  the  uterus  pos- 
sesses a  mucous  surface.  During  several  weeks,  no  organ  of  the 
foetus  is,  properly  speaking,  invested  with  a  mucous  membrane  ;  not 
one  of  them  can  be  divided  into  lamellae  of  different  natures  ;  they 
are  all  formed  of  a  homogenous  tissue  ;  the  intestines,  like  the  other 
hollow  organs,  are  possessed  not  of  internal  and  external  membranes, 
but  of  surfaces  ;  it  is  only  at  a  later  period,  little  by  little,  and  in  the 
same  situations  where  they  are  observed  after  birth,  that  the  distinc- 
tion of  tissues  established  by  the  zoologists  are  effected.  Thus,  the 
interior  of  all  the  cavities,  of  all  the  canals  that  communicate  nearly 
or  remotely  with  the  atmosphere,  exhibit  the  aspect  of  villous  sur- 
faces ;  but  to  this  fundamental  character  are  added  others  which 
differ  according  to  the  organ,  and  reduce  every  portion  into  har- 
mony with  the  uses  of  the  parts  it  helps  to  constitute.  Sometimes 
it  is  a  movable  lamina,  thick  and  wrinkled,  as  in  the  alimentary 
canal ;  in  other  instances  it  is  a  thin  smooth  layer,  difficult  to  sepa- 
rate from  the  subjacent  tissues,  as  in  the  ureters,  the  vasa  deferen- 
tia,  &c.  Although  follicular  and  villous,  this  element  may  adhere 
so  intimately  to  the  substance  of  the  organs,  that  it  is  impossible  to 
separate  it ;  and  this  is  the  case  with  the  womb.  Nature,  true  to 
her  great  principle,  seems  here  to  take  pleasure  in  varying  forms 
without  multiplying  means ;  on  some  points  she  is  content  with  a 
mere  rudiment,  while  at  other  points  she  at  once  attains  p*erfection  ; 
but  on  the  other  hand,  that  which,  so  to  speak,  she  leaves  incomplete 
in  the  normal  state,  is  rendered  complete  by  a  disease,  or  by  some 
eventual  condition  ;  in  tliis  way  it  happens  that  a  pregnancy,  a  poly- 
pus, or  some  other  lesion,  have,  in  more  than  one  instance,  rendered 
the  mucous  membrane  of  the  uterus  altogether  evident. 

167.  e.  Peculiar  tissue^  or parenchyTna.  Situated  between  the  two 
preceding  layers,  and  alone  constituting  almost  the  entire  essential 
and  fundamental  part  of  the  organ,  the  proper  tissue  of  the  womb 
has  been  the  subject  of  the  researches  of  a  great  many  very  able 
anatomists.  Bonacciolus,  Swammerdam,  Meckel  and  Ruysch, 
Noorthwyck,  Sue,  Hunter,  Loder,  Weisse,  M.  Lobstein,  Belloni, 
and  very  recently  Madame  Boivin,  have  striven  to  demonstrate  its 
texture,  before,  during,  and  after  pregnancy  ;  but  in  spite  of  so  many 


64  OF  THE  SEXUAL  ORGANS. 

exertions,  opinions  are  still  far  from  being  unanimous  in  regard  to 
its  nature. 

168.  Nature  of  the  peculiar  tissue  of  the  womb .  The  same  thing 
has  taken  place  in  regard  to  the  womb,  as  always  occurs  in  anatomy, 
whenever  the  analogies  and  comparisons,  which  authors  are  obliged 
to  draw  for  the  purpose  of  illustrating  their  ideas,  are  rigorously 
construed  according  to  the  letter.  When  Vesalius  asserted  that  the 
womb  is  a  muscle,  Walter,  taking  the  muscles  of  the  skeleton,  and 
even  the  heart  or  the  intestines  as  his  type,  found  no  difficulty  in 
proving  that  Vesalius  had  made  a  mistake.  Although,  on  the  one 
hand,  Malpighi,  Ruysch,  Noorthwyck,  Wrisberg,  Meckel,  Lobstein, 
and  the  major  part  of  modern  anatomists,  have  arranged  themselves 
on  the  side  of  Vesalius,  we  see  on  the  other,  Boehmer,  Blumenbach, 
&c.,  alleging  reasons,  that  are  apparently  very  plausible,  to  prove 
that  it  is  at  least  not  founded  on  the  state  of  the  organ  when  unim- 
pregnated.  Both  sides  have  often  been  right;  but,  by  referring  to 
forced  approximations,  they  have  too  often  lost  sight  of  the  object 
to  render  it  possible  to  reconcile  so  many  various  observations. 

Previously  to  asserting  that  the  womb  does  or  does  not  contain 
muscular  tissue,  it  would  have  been  proper  to  determine  what  are 
the  characters  of  that  tissue  in  general ;  to  show  that  the  red  colour 
is  not  essential  to  it,  since  it  is  wanting  in  the  muscles  of  fishes, 
reptiles,  and  even  in  the  muscular  coat  of  the'human  intestines  ;  and 
that  the  same  is  true  of  the  fibrous  appearance,  since  it  is  met  with 
in  the  tendons,  aponeuroses,  &.c.,  but  that  it  alone  enjoys  the  faculty 
of  contractility,  and  contains  fibrine. 

In  the  second  place,  it  should  be  considered  indispensable  to  re- 
cognize a  truth  that  is  too  much  overlooked  in  our  days  :  which  is, 
that  the  fleshy  fibre  must  necessarily  pass  through  several  less  perfect 
gradations  of  development;  that,  in  some  organs,  it  remains  in  the 
rudimcntal  condition,  and  is  developed  only  by  accident.  Thus, 
the  trachea,  and  the  bronchia,  even  tlie  arteries  of  large  animals,  the 
elephant  among  others,  evidently  exhibit  muscular  fibres,  while  the 
same  organs  in  the  human  species  rarely  exhibit  them  with  any  dis- 
tinctness. The  gall  bladder,  the  vesicula;  scminales,  »fcc.  are  not 
furnished  with  them,  according  to  most 'of  the  modern  anatomists  ; 
but  let  these  organs  be  examined  when  their  coats,  strongly  hyper- 
trophied,  have  been  long  distended,  and  wc  shall  be  soon  forced  to 
admit  that  they  possess  a  muscular  coat,  as  the  ancients  believed, 
and  as  1  have  seen  myself.  The  womb,  previously  to  puberty,  is 
only  a  rudimcntal  muscle  ;  when  not  gravid,  its  organization,  it  is 
true,  is  but  a  sketch,  but  it  is  only  towards  the  end  of  pregnancy 
that  we  can  possibly  test  its  nature.     Every  circumstance  tends  to 


OF  THE  SEXUAL  ORGANS.  65 

establish  that  the  cellulo-fibrous,  elastic  yellow  tissue  which  com- 
poses the  basis  of  the  inter-laminar  and  inter-spinal  ligaments  of  the 
vertebras,  constitutes  also  the  web  of  a  very  great  variety  of  other 
organs.  It  is  no  where  more  abundant  than  in  the  uterus.  Hence 
it  appears  that  this  element  holds  a  middle  place,  and  serves  in  some 
^  sort  as  a  passage  between  the  cellular  and  muscular  systems ;  the 
chemists  have  detected  fibrine  in  it,  and  I  have  seen  it,  on  various 
points,  transformed  into  real  contractile  tissue.  I  am  scarcely  afraid 
to  assert  that  wherever  it  is  met  with,. it  may  accidentally  develope 
muscular  fibres,  and  that  these  fibres  exist  naturally  in  some  zoolo- 
gical species. 

169.  In  order,  therefore,  to  understand  the  essence  of  the  uterine 
.  tissue,  it  ought  to  be  studied  during  its  gravid  state  :  then  only  is  it 

red,  contractile,  formed  of  tomentose  fibres  ;  then  only  does  it  con- 
tain a  great  proportion  of  the  fibrine ;  and  presents,  in  a  word, 
all  the  characters  of  the  most  perfect  muscular  tissue. 

170.  Disposition  of  the  fibres.  Vesalius,  Malpighi,  and  the  first 
j^natomists  who  admitted  their  existence,  contented  themselves 
jvith  saying  that  the^  fibres  of  the  womb  are  so  interlaced,  that 
it  is  impossible  to  trace  out  their  direction.  Ruysch  and  some 
others  advgjnced,  that  being  principally  collected  about  the  fun- 
dus of  the  organ,  they  compose  an  orbicular  muscle,  a  sort  of  disc, 
the  use  of  which  is  to  detach  the  placenta  at  the  period  of  labour. 
Hunter,  Sue,  &c.  admit  that  it  forms  a  number  of  layers  variously 
crossed  ;  A.  Leroy  teaches  that  they  give  rise  to  two  layers  of 
muscles,  one  internal  and  one  external ;  and  M.  Meckel,  who  in 
common  with  several  German  anatomists,  partially  adopts  this  sen- 
timent, thinks  that  each  of  the  two  pjuicipal,  layers  ought  to  be  di- 
vided into  several  other  secondary  layers.  Baudelocque,  and  most 
of  the  French  anatomists,  abandoning  all  hopes  of  assigning  to  these 
fibres  a  determinate  direction,  have  contented  themselves  with  teach- 
ing that  they  are  disposed  in  loops,  parallel  to  the  axis  of  the  uterus, 
or  in  horizontal  circles  ;  that  the  body  and  fundus  of  the  womb  are 
chiefly  composed  of  the  former,  while  the  latter  are  found  more 
especially  in  the  neck.  Indeed  it  will  be  hereafter  seen  that  great 
stress  has  latterly  been  laid  on  this  idea,  which  is  relied  on  for  the 
Explanation  of  the  process  by  which  the  cervix  is  effaced  during 
pregnancy,  and  dilated  in  labour,  &c.,  and  also  the  occasional 
causes  of  parturition.  Lastly,  Madame  Boivin,  to  whom  we  are 
indebted  for  some  valuable  researches  on  this  subject,  has  observed 
a  much  greater  number  of  fleshy  layers  in  the  womb  than  any  pre- 
ceding author.  She  admits,  1 .  A  longitudinal  fascicle,  wl^ich  oc- 
cupies the  median  line  in  front  and  rear ;  and  extends  from  the  fun- 

l 


66  OF  THE  SEXUAL  ORGANS. 

dus  to  the  neok ;  2.  On  each  surface  of  the  organ,  and  on  both  sides 
of  the  vertical  column  three  layers"  of  transverse  fibres,  which  pro- 
ceed to  lose  themselves,  outwards,  in  the  tubes,  the  ligaments  of  the 
ovaries,  the  round  ligaments,  and  the  posterior  ligaments ;  3.  At 
the  superior  angles  of  the  uterus,  and  deeply  seated,  a  circular  layer, 
the  centre  of  which  corresponds  to  the  origin  oi"the  tubes,  and  which 
interlaces  and  confounds  itself  with  the  opposite  one  ;  4.  And  lastly, 
Very  near  the  mucous  surface,  a  layer  that  is  thinner  than  any  of  the 
others.  *  • 

I  have  myself  dissected  a  very  great  number  of  wombs,  at  every 
period  of  age,  both  unimpregnated  and  during  the  gravid  state,  and  I 
am  convinced  that  each  of  these  modes  of  regarding  the  subject  has 
some  foundation.  The  imbrication  noticed  by  Malpighi  and  his 
predecessors  is  not  to  be  disputed,  and  does  not  exclude  the  exis- 
tence of  the  muscle  spoken  of  by  Ruysch.  This  last  author,  although 
opposed  by  lleister,  Haller,  &;c.  was  .almost  entirely  right :  it  suf- 
fices merely  to  examine  the  inner  surface  of  the  womb,  at  the  close 
of  pregnancy,  to  recognize  the  stratum  of  muscular  fibres  he  men- 
tions ;  only,  instead  of  one  orbicular  disc  admitted  by  the  celebrated 
Dutch  anatomist,  there  are  two.  The  two  layers  spoken  of  by  A. 
Leroy,  Rosenberger,  M.  Meckel,  &c.  are  completely  apparent  in 
the  last  month  of  gestation  ;  but  it  must  not  be  expected  that  tliey 
can  be  found  independent  of  each  other.  Considered  in  a  general 
manner,  all' these  peculiarities  agree  together  very  well,  and  further, 
they  agree  with  the  sentiment  of  those  who  insist  upon  it  that  the 
wpmb  contains  none  but  fibres  arranged  in  loops  or  vertically,  and 
in  circles  or  horfzontally. 

171.  Conclusions.  ^Upoffl|the  whole,  tlie  following  are  what  I 
have  most  invariably  observedon  this  subject.  1.  Beneath  the  peri- 
toneum there  is  a  first  stratum  th^  is  thin,  dense,  elastic,  cellulo- 
fibrous,  and  sometimes,  but  not  always,  muscular,  in  which  the 
fibres  have  no  determinate  direction  ;  2.  A  thicker  lay^pr^pf  transverse 
fibres,"  which,  united  in  different  planes,  and  imbricated  like  the  con- 
strictor muscles  of  the  pharynx,  all  tend  outward^,  and  converge 
towards  the  four  principal  points  mentioned  by  Madame  Boivin ; 
3.  More  deeply  sealed,  arc  found  other  transverse  fibres  ;  but  the 
longitudinal  and  oblique  fibres  predominate,  especially  at  the  neck, 
where  they  constitute  the  basis  of  the  ridges  observed  on  the  inner 
surface  of  the  organ  ;  lastly,  above  is  seen  the  protended  detrusor 
jpZaccn/<E  of  Ruysch,  which  seems  to  be  nothing  more  than  an  ex- 
pansion of  the  circular  fibres  of  the  Fallopian  tubes. 

The  basis  of  all  these  strata  is  the  yellow  cellulo-fibrous  tissue, 
surcharged  with  fibrine  ;  the  fleshy  tissue  developes  itself  in  this  pri- 
mitive web  as  in  the  intestines  ;  but  inasmuch  as  the  womb  seems  to 


OF  THE  SEXUAL  ORGANS.  67 

be  composed  by  the  union  of  two  cylindrical  canals,  and  as  it  is 
necessary  that  it  should  be  endowed  with  great  strength,  it  is  not  as- 
tonishing that  its  multiplied  fibres  should  affect  the  most  complex 
and  varied  directions. 

172.  d.  Blood-vessels.  Two  orders  of  arteries  are  appropriated 
to  the  gestative  organs  :  one,  known  as  the  uterine  arteries,  furnish- 
ed by  the  hypogastrics,  penetrate  into  the  substance  of  the  womb  at 
the  cervix  ;  the  others,  the  ovarian,  given  off  by  the  aorta  or  the 
emulgents,  pass  along  in  the  broad  ligaments,  arid  after  being  partly 
distributed  in  the  ovaries,  proceed  to  the  sides  of  the  body  of  the 
womb  itself.  In  ramifying,  those  of  the  left  side  inosculate  with 
those  of  the  right,  those  from  above'with  those  from  below,  and  as 
all  of  them  are  strongly  compressed  in  the  substance  of  the  tissue  in 
which  they  creep,  they  are  doubled  and  redoubled  a  great  many 
times.  The  veins,  distributed  in  the  same  manner  as  the  arteries, 
gp  to  the  internal  iliac  vein  from  one  part,  and  to  the  ovarian  veins 
ijpra  the  other.  During  pregnancy,  these  various  canals,  partially  un- 
folded and  lai'gely  dilated,  run  chiefly  between  the  two  fleshy  strata 
so  much  insisted  upon  by  A.  Leroy. 

173.  c.  Its  lymphatic  vessels  pass  into  the  pelvic  and  ifiac  gang- 
lions ;  its  nerves  come  from  the  sacral  plexus,  and  from  the  gangli- 
onic system  by  the  renal  and  hypogastric  plexuses.  The  former 
are  distributed  almost  exclusively  upon  the  cervix,  and  if  is  natural 
to  attribute  to  them  the  excessive  sensibility  enjoyed  by  this  part ; 
while  the  latter,  being  here  destined  to  furnish  only  the  vegetative 
sensibility,  must  be  more  regularly  distributed  to  all  parts  of  the 
womb. 

§.  ir.  Fallopian  tubes  [iubce  Fallopiano;). 

174.  The  uterine  tubes,  or  Fallopian  tubes,  (seminiferous  ducts) 
are  two  small,  hollow  cylinders,  four  or  five  inches  long,  as  large 
as  the  barrel  of  a  quill,  and  extending  from  the  lateral  angles  of  the 
womb,  with  which  they  are  continuous,  to  near  the  iliac  fossae, 
where  they  terminate  in  a  laciniated  and  loose  extremity,  called  tlfe 
devil's-bit  {morsus  diaboli,)  or  fimbriated  extremity  of  the  tube. 
This  tortuous  tube  is  inclosed  in  the  upper  edge  of  the  broad  liga- 
ment ;  its  cavity,  which,  at  the  womb,  is  large  enough  to  admit  of  a 
middle  sized  probe,  at  first  contracts  by  degrees,  so  that  near  its 
middle  a  bristle  can  scarcely  be  passed  through  it,  it  then  enlarges, 
and  soon  acquires  a.  diameter  of  two  or  three  lines.  Among  the 
fringes  which  terminate  its  loose  extremity  is  one  that  is  harder  and 
longer  than  the  rest,  which  fixes  itself  to  the  ovary,  and  seems  to  be 
the  real  continuation  of  the  tube. 


68  OF  THE  SEXUAL  ORGANS. 

175.  Structure.  The  composition  of  the  seminiferous  tubes  is  in 
all  respects  similar  to  that  of  the  uterus  itself.  They  are  enveloped 
externally  by  the  peritoneum,  which  adheres  closely  to  them,  and  a 
mucous  membrane,  folded  in  the  direction  of  their  length,  lines  them 
within.  A  pretty  thin  layer  of  fleshy  fibre  is  found  betwixt  these 
two  laminae ;  its  fibres  are  of  two  sorts,  like  as  in  the  small  intes- 
tines :  one  sort,  longitudinal,  are  only  a  prolongation  of  the  trans- 
verse stratum  of  the  surface  and  fundus  of  the  uterus  ;  the  others, 
which  are  circular,  cut  the  former  at  right  angles,  and  seem  to  be 
appendages  of  the  orbicular  muscle  of  Ruysch.  As  to  the  internal 
coat,  its  existence  has  been  denied  ;  but  to  the  proofs  related  above, 
(166)  I  may  add,  that  in  a  woman  of  middle  age,  I  and  M.  Baude- 
locque,  Jun.  saw  the  mucous  membrane  of  the  Fallopian  tube  as. 
movable,  and  as  easily  separable,  as  it  is  in  the  oesophagus  ;  its  valvu« 
lar  folds,  mentioned  by  those  authors  who  assert  that  the  ovule  may 
easily  pass  to  the  womb,  but  cannot  possibly  retrograde  towards  the 
ovary,  and  especially,  that  the  semen  masculinum  cannot  pa^ 
through  the  tube,  have  been  the  products  only  of  the  imagination  of 
those  who  needed  them  for  the  defence  of  their  preconceived  theories. 
The  tubes  receive  all  their  vessels  from  the  ovarian  branches  ;  their 
nerves  belong  to  the  great  sympathetic,  and  like  the  uterus,  their 
basis  is  an  elastic,  fibrous,  cellular  tissue. 

§.  III.  Ovaries  (ouaria) . 

176.  The  ovaries,  long  known  as  the  testes  muliebres,  and  which 
may  be  called  the  female  seminal  glands,  are  situated  in  the  upper 
part  of  the  broad  ligaments,  behind,  and  a  little  below  the  tubes, 
near  the  superior  angles  of  the  uterus,  to  which  they  are  attached 
by  the  ligament  of  the  ovary.  Oblong,  slightly  flattened  from  front 
to  rear,  being  of  the  size  and  almost  of  the  shape  of  an  almond  or  a 
large  bean,  the  ovaries  have  a  superior,  convex  and  loose  edge,  while 
their  inferior  edge  is  straight,  receives  vessels,  and  proceeds  to  join 
the  ovarian  fringe  of  the  tube.  Their  surface  even,  or  scarcely 
botryoidal  in  women  who  have  never  been  fecundated,  presents,  on 
the  contrary,  in  those  who  have  had  children,  inequalities,  fissures 
and  reliefs  in  a  greater  or  less  degree.  Difl>3ring  as  much  both  in 
appearance  and  nature  from  the  salivary  glands  to  which  Pean  com- 
pared them,  as  they  do  from  the  seminal  glands  of  the  male,  the 
ovaries  possess  a  structure  which  is  peculiar  to  themselves,  as  is  the 
case  in  all  the  special  organs.  A  sort  of  parenchyma  of  a.  reddish 
grey  colour,  composed  of  lamellae  and  filaments  variously  interlaced, 
constitute  their  principal  tissue.  Since  the  time  of  R.  De  Graaf,  it  is 
admitted  that  there  really  do  exist  in   this   parenchyma  certain 


OF  THE  SEXUAL  ORGANS.  69 

transparent  vesicles,  from  twelve  to  twenty  in  number,  and  which 
are  denominated  ovules  or  germs.  In  it  also  we  occasionally  meet 
with  accidental  vesicles,  true  hydatids,  which  should  not  be  con- 
founded with  the  former,  but  which  may  possibly  be  only  degene- 
rated ovules.  According  to  De  Graaf,  "  vessels  and  preparative 
nerves  enter  into  these  vesicles,  on  the  tunics  of  which  several  of 
their  branches,  after  various  divarications,  distribute  themselves,  as 
occurs  in  the  yolk  of  the  egg  while  it  is  still  attached  to  its  ovary." 
A  strong,  thick,  and  very  tough  membrane  serves  as  the  shell  or 
envelope  of  this  tissue;  and  according  to  my  observations,  this  fibrous 
membrane  is  only  an  appendage  of  the  ligament  of  the  ovary  ;  that 
is  to  say,  the  ligament  of  the  ovary,  which  is  one  or  two  inches  in 
length,  and  one  or  two  lines  thick,  is  formed  by  a  fascicle,  from  the 
transverse  layer  of  the  posterior  surface  of  the  uterus,  and  when  it 
reaches  the  point  of  the  seminal  gland,  its  fibres  separate  in  order  to 
envelope  the  parenchyma  in  question.  It  is  evident  that  the  proper 
tunic  of  the  ovary  is  altogether  distinct  from  the  peritoneal  layer, 
from  which,  however,  it  is  impossible  to  separate  it.  In  naming  it 
•dartos^  it  is  probable  tliat  the  ancients  did  not  suppose  that  like  the 
dartos  of  the  male,  it  approaches  by  its  nature  very  nearly  to  the 
contractile  or  muscular  tissue. 

177.  Until  the  time  of  Fallopius,  it  was  generally  taught  that  the 
germ  was  carried  from  the  ovary  to  the  uterus  by  different  canals, 
of  which  the  tube  did  not  constitute  any  pjyi't ;  the  ligament  of  the 
ovary  was  supposed  to  be  the  principal  one  ;  it  formed  the>  deferent 
canal.  Warthon  and  Mauriceau  admitted  one  or  two  others,  which 
passed  from  the  edge  of  the  ovarium  and  opened  into  the  vagina  ; 
but  it  was  long  ago  demonstrated  that  the  ligamentous  cord  of  the 
ovary  is  solid,  and  contains  no  CJinal ;  however,  the  other  passage, 
also  forgotten  for  a  whole  age,  has  just  been  recalled  to  the  attention 
of  naturalists  by  M.  Gartner  of  Copenhagen,  who  looks  upon  it  as 
an  organ  that  is  always  to  be  met  with  in  the  large  quadrupeds.  I 
have  vainly  sought  for  it  in  the  human  subject,  and  found  nothing 
even  remotely  resembling  it.  The  ovary  is  the  essential  organ  of 
generation,  the  organ  in  which  germs  are  formed. 

§.  IV.  Ligaments  of  the  uterus. 

178.  In  investing  the  internal  organs  of  generation,  the  peri- 
toneum gives  birth  to  several  ligamentous  folds,  which  it  is  proper 
now  to  describe. 

Of  these,  the  chief  are  the  broad  ligaments,  which  constitute  a 
transverse  partition,  and  divide  the  whole  depth  of  the  pelvis  into 
two  cavities,  one  anterior  and  the  other  posterior ;  in  the  former  the 


7Q  OF  THE  SEXUAL  ORGANS. 

bladder  is  situated,  and  in  the  latter,  which  is  deepest,  is  found  the 
i-ectum  ;  the  two  lamina  of  the  peritoneum,  of  which  the  broad 
lio-aments  are  composed,  separate  when  they  reach  the  sides  of  the 
womb,  in  order  to  spread  out  on  its  surfaces ;  downwards  and  out- 
wardly, they  also  deploy  so  as  to  be  continuous  with  the  peritoneum 
which  lines  the  cavity  of  the  pelvis  ;  their  superior  border,  which  is 
loose,  extending  from  the  angles  of  the  uterus  to  the  iliac  fossa,  is 
divided,  as  it  were,  into  two  or  three  secondary  folds,  which  are 
called  its  lesser  wings  :  one  of  these,  the  posterior,  encloses  the 
ovary  and  its  ligaments  ;  another  (the  middle  one  according  to  M. 
Dubois  and  the  other  authors  who  admit  three  of  them  ;  but  the 
anterior  one,  according  to  Baudelocque,  M.  Desormeaux,  and  all 
the  accoucheurs  who  contend  that  there  are  only  two)  contains  the 
Fallopian  tube,  and  is  the  highest ;  the  third,  mentioned  by  some 
and  rejected  by  others,  and  which  is  in  fact  scarcely  distinguishable 
in  the  natural  state,  is  found  in  front  of,  and  lower  down  than  either 
of  the  preceding  ones,  and  encloses  the  round  ligament.  The  two 
serous  laminae  of  the  broad  ligament  are  not  in  immediate  contact ; 
they  are  separated  by  a  layer  of  cellular  tissue,  of  various  thickness* 
in  different  individuals,  and  this  layer,  which  downwards  and  out- 
wards becomes  blended  with  the  sub-peritoneal  cellular  tissue  or  the 
fascia  propria  of  the  pelvis  and  iliac  fossae,  is  sometimes  found  to 
contain  muscular  fibres ;  so  that  we  find,  in  the  broad  hgaments, 
nearly  the  same  elemegt|!  as  in  ,the  womb  itself. 

179.  The  round  ligaments  or  sur-pubic  cords^  fibrous  bundles, 
which  take  their  rise  in  front  of  and  a  little  below  the  Fallopian  tubes, 
follow  the  outline  of  the  anterior  semi-circumference  of  the  superior 
strait,  and  proceed,  after  passing  through  the  inguinal  rings,  to  ter- 
minate in  the  groins  and  mons  Veneris,  are  the  only  ones  which  have 
been  deemed,  with  the  broad  liganfients,  worthy  of  attention.  Formed 
of  reddish  and  wavy  fibres,  which  rise  from  the  anterior  and  middle 
transverse  layers  of  tlie  womb,  the  round  ligaments  are  evidently  of 
a  muscular  nature.  Dionis  asserted  that  the  use  of  the  round  liga- 
ments was  to  depress  the  os  tinea;  by  contracting  during  the  sexual 
embrace,  and  thus  to  bring  it  closer  to  the  m^le  organ  ;  but  as  their 
origins  arc  lower  than  their  insertions,  it  is  manifest  that  their  con- 
traction in  that  case' would  pi*oduce  a  rath^  cpnlrary  eflect.  But 
further,  the  womb  without  them  would  be  always  retroverted  by  the 
bladder,  which  is  'repeatedly  distcrtdcd  with  ^urine  in  the  course  of 
every  tweniy-four  hours :  they  also"  uphold  it  until  towards  the  mid- 
dle of  pregnancy;  but  further  than. this  nothing  is  certainly  known  in 
regard  to  their  uses,  and  there  is  no  occasion  for  me  to  enter  into  an 
argument  against  the  opinion  of  the  ancients,  especially  of  Spigelius, 


OF  THE  SEXUAL  ORGANS.  71 

who  supposed  that  the  semen  passed  through  them  in  its  passage  to 
the  clitoris.  Being  put  on  the  stretch  by  the  ascent  of  the  womb, 
it  is  possible  that  they  may,  when  the  woman  is  on  foot,  and  parti- 
cularly when  on  her  knees,  occasion  pretty  smart  pains  in  the  groins 
and  thighs. 

180.  Douglass,  A.  Petit,  Sue,  &c.  have  noticed  four  other  liga- 
ments, two  anterior  (utero-vesical  of  Madame  Boivin),  and  two  pos- 
terior (utero-sacral^  id.) ;  the  two  former,  very  small  in  most  women, 
passing  from  the  sides  of  the  cervix  uteri  to  the  lateral  parts  of  the 
j^  *  "TjBS-fond  of  the  bladder,  are  occasionally  composed,  in  addition  to 
-'^P'^heir  peritoneal  coat,  of  a  few  fleshy  fibres,  that  seem  to  be  detach- 
ed from  the  antero-inferior  transverse  layer  of  the  neck  of  the  womb. 
The  latter,  which  are  much  stronger  and  more  constantly  observed, 
originate  a  little  lower  down,  from  the  posterior  surface  of  the  cer- 
vix, run  backwards,  each  forming  a  crescent,  the  concavity  of  which 
looks  towards  tht  median  line,  and  are  attached  to  the  sides  of  the 
Kctum,  where  they  are  lost  in  the  cellular  tissrfe  arid  peritoneum 
which  invests  the  front  of  the  sacrum ;  from  numerous  facts  that 
have  come  under  my  notice,  I  am  of  the  opinion  that  they  are  of 
the  same  nature  as  the  round  ligaments,  and  that  their  fleshy  fibres 
are  furnished  by  the  postero-inferior  transverse  layer  of  the  uterus  j 
consequently,  it  may  be  conceived  that  they  may  tend  to  prevent  the 
retroversion  of  the  womb,  and  be  in  this  respect  congeners  of  the 
round  ligaments  ;  that  their  use  is  to  prevent  the  os  tincae  from  being 
carried  forwards ;  and  that  the  knowledge  of  them  isfar  from  being 
unimportant  to  the  accoucheur. 

§.  V.  Of  the  Vagina. 

181.  The  vagina  or  vulvo-uterine  canal,  an  organ  for  eduction 
and  copulation,  is  a  cylindrical  canal,  four  or  five  inches  long,  by 
about  an  inch  in  diameter,  which  extends  from  the  vulva,  where  it  is 
continuous  with  the  labia  and  hymen,  up  to  the  neck  of  the  uterus, 
to  whose  circumference  it  is  attached.  Its  direction  is  nearly  paral- 
lel to  that  of  the  posterior  walUof  the' excavation,  that  is  to  say,  it  is 
concave  in  front,  and  convex  posteriorly,  is  situated  in  the  axis  of 
the  inferior  strait,  and  forms  an  angle  of  about  siity-five  degrees 
with  the  great  diameter  of  the  womb.  From  this'  disposition,  it 
happens  that  its  posterior  wall  is  much  longer  than  the  anterior,  and 
its  two  extremities  being  inclined  towards  each  other  in  front,  re- 
present pretty  correctly  the  planes  of  the  two  straits  of  the  pelvis. 

182.  Connexions.  Thfe  posterior  region  of  its  external  surface, 
resting  for  the  middle  three-fifths  of  its  whole  extent  on  the  fore  part  of 
the  rectum,  assists  in  forining  the  recto-vaginal  septum ;  in  approach- 


72  OF  THE  SEXUAL  ORGANS. 

ing  the  vulva  its  lower  fifth  leaves  the  rectum,  at  a  distance  equal  to 
the  whole  thickness  of  the  perineum  ;  its  superior  fifth,  loose  in  the 
pelvis,  is  invested  by  the  peritoneum.  Its  anterior  region  is  con- 
nected by  means  of  a  dense  and  firm  cellular  tissue,  first  to  the  bas- 
fond  of  the  bladder,  so  as  to  form  the  vesico-vaginal  septum,  then  to 
the  urethra,  which  gives  rise  to  the  urethro-vaginal  septum.  The 
sides  of  the  vagina  are  surrounded  with  vessels,  nerves,  and  a  very 
abundant  cellular  tela. 

183.  The  interior  of  the  vagina  presents  a  number  of  wrinkles  or 
folds,  analogous  to  those  which  are  met  with  in  the  cavity  of  the 
cervix:  the  middle  column  of  its  parietes,  sometimes  divided  into 
two,  three,  or  four  small  parallel  columns,  increases  in  thickness  as 
we  approach  nearer  to  the  vulva  ;  the  same  is  true  of  the  transverse 
folds ;  so  that  the  vagina,  which  is  smooth,  or  almost  smooth  above, 
is  most  conimonly  rugose  and  plaited  below,  like  the  palate  in  the 
ruminating  animals.  I  have  already  stated  (144)",  that  below  the 
meatus  urinarius  and  at  the  fourchette,  these  two  middle  columns 
constitute  the  anterior  and  posterior  myrtiform  caruncles.  Larger 
in  yopng  persons  who  have  iiever  cohabited,  and  in  brunettes  with  a 
dry  fibre,  than  in  women  who  are  in  an  opposite  condition,  all  these 
wrinkles  are  effaced  during  labour,  but  in  general,  reappear  soon 
afterwards. 

184.  The  vaginal  cavity  terminates  above  in  a  circular  groove, 
or  cul  de  sac,  much  deeper  behind  than  in  front.  Supple,  thin,  and 
situated  between  organs  liable  to  alternate  dilatation  and  contraction, 

•  the  sides  of  the  vagina  are  habitually  in  almost  complete  contact; 
but,  as  they  are  endowed  with  great  sensibility,  it  happens  thatHhe 
capacity  of  the  vulvo-uterine  canal  varies  considerably.  Sometimes 
it  is  found  to  be  wider  at  its  middle  than  in  any  where  else,  and 
that  is  because  the  womb  is  too  much  depressed  ;  at  other  times  it 
is  only  the  superior  ,portion,  especially  in  women  who  have  had 
children,  thai  is  found  dilated  as  it  Were  ;  which  depends  on  the 
neck  of  the  uterus  having  remained  after  delivery  lower  than  it  was 
before  marriage.  In  fine,  we*  shall  ^ardly  find  it  of  equal  dimen- 
sions throughout,  excef>t  in  those  who  have  scarcely  ever,  as  yet, 
yielded  themselves  up  to  venereal  enjoymenfe. 

185.  Structure.  Two  layers  enter  into  its  composition:  one,  ex- 
ternal, a  real  prolongation  of  the  external  lanrtinse  of  the  uterus,  has, 
for  its  basis,  the  yellow  cellulo-fibrous  tissue,  and  contains  a  small 
number  of  interlaced,  very  pale  muscular  fibres,  which  must  not  be 
confounded  with  the  elliptical  muscular  rings  of  its  vulvar  orifice, 
and  which  belong  to  the  constrictor  vaginai  muscle.  These  latter, 
indeed,  act  under  obedience  to  the  will ;  the  former,  on  the  contrary, 


OF  THE  SEXUAL  ORGANS.  73 

are  not  brought  into  play  except  by  the  gratifications  of  love.  Ar- 
teries, and  more  especially  numerous  veins,  pass  through  this  tissue, 
and  form,  particularly  below,  a  real  spongy  or  erectile  stratum,  which 
swells  under  the  frictions  of  coition,  and  may  then  contract  so  much 
as  manifestly  to  diminish  the  width  of  the  vagina. 

186.  The  other,  zntemaZ,  is  continuous  with  the  mucous  mem- 
brane of  the  vulva,  and  is  blended,  on  the  lips  of  the  cervix,  with 
that  which  lines  the  cavity  of  the  womb  ;  that  half  which  is  nearest 
the  pudendum  presents  all  the  characters  of  the  most  perfect  mu- 
cous laminae ;  in  it  are  found  an  epithelium,  follicles,  villi,  &c.  Near 
the  neck  it  cannot  be  separated  from  the  subjacent  tissues,  and,  at 
that  point,  nothing  demonstrates  the  existence  of  follicles  and  villi. 
It  covers  all  the  duplicatures  of  the  vagina,  but  does  not  compose 
them,  whatever  may  have  been  said  to  the  contrary  by  a  crowd  of 
authors.  The  mucous  follicles  are  principally  seated  at  the  bot- 
tom of  these  folds,  where  also  the  venereal  chancre  is  found  to  be 
occasionally  concealed. 

187.  Two  small  glands,  noticed  from  time  immemorial  by  the 
anatomists,  under  the  name  of  vaginal  glands^  or  prostates  of  Bar- 
tholin, and  which  have  been  erroneously  classed  among  the  simple 
follicles,  are  to  be  seen  under  the  lateral  myrtiform  caruncles,  be- 
twixt the  mucous  membrane  and  the  muscular  coat :  their  uses  are 
little  understood  ;  M.  Gartner,  however,  thinks  they  may  serve  as 
the  point  of  origin  or  termination  of  the  canal  discovered  by  him. 

§.  VI.  Of  the  sexual  organs  in  general. 

188.  The  sexual  organs,  taken  as  a  whole,  and  regarded  in  a 
philosophical  hght,  may  be  considered  as  a  dependency  of  the  tegu- 
mentary  laminae;  that  is  to  say,  the  mucous  membrane  consti- 
tutes the  most  important  and  constantly  present  portion  of  them.  In 
the  lower  animals,  as  well  as  in  those  whose  sexual  system  is  in  the 
highest  degree  complex,  the  germs  are  always  created  at  the  bot- 
tom of  a  mucous  cavity,  whether  it  consist  of  a  simple  excavation, 
or  constitutes  a  canal  that  is  straight,  tortuous,  &c.  However,  the 
generative  cavity  is  sometimes  composed  of  a  doubled  homogeneous 
lamina,  of  equal  thickness  throughout  its  whole  extent,  as  in  worms, 
and  the  species  that  have  no  uterus  ;  sometimes,  on  the  contrary,  this 
duplicature  is  at  first  very  thin  in  one  portion  of  its  extent,  becomes 
in  the  next  place  very  thick  at  another  point,  and  gradually  becomes 
thin  again  in  a  third,  as  is  the  case  in  women. 

189.  Although,  in  the  human  species,  the  generative  apparatus 
forms,  as  it  does  in  brutes,  only  a  long  canal  reaching  from  the 
ovary  to  the  vulva,  it  exhibits  to  us,  nevertheless,  one  of  the  most 

K 


74  OF  THE  SEXUAL  ORGANS. 

perfect  of  iJie  secretory  appj^ratuses.  The  ovaries  constitute  its 
glandular  portion,  the  uterus  is  the  reservoir,  and  the  vagina  the 
excretory  duct ;  so  that  they  may,  in  respect  to  their  peculiar  func- 
tions, be  divided  into  formative,  productive,  and  transmitting  organs 
(the  ovaria  and  tubes),  into  gestative  organ,  (the  womb),  and  into 
eductive,  conjunctive,  or  copulative  organs  (the  vagina  and  vulva). 

§.  VII.  Varieties  in  the  internal  organs  of  generation  in  ani- 
mals. 

190.  A  long  tube,  extremely  thin,  double,  wound  upon  itself 
within  the  body  of  the  animal,  and  terminating  in  a  sort  of  vagina, 
performs  all  the  generative  functions  in  the  lumbricoid  worms. 
Fishes  possess  enormous  ovaries,  which  contain  as  many  as  two 
hundred  thousand  ovula,  are  continued  without  interruption  into  the 
oviducts  or  tubes,  and  have  a  directly  external  opening.  The  ova- 
ries of  reptiles  resemble  bunches  of  grapes,  but  of  various  lengths ; 
in  birds  they  present  numerous  cells,  in  which  the  eggs  are  lodged ; 
the  oviduct,  always  open  and  trumpet  shaped  at  its  superior  extre- 
mity, terminates,  below,  in  the  cloaca,  which  supplies  the  place  of  a 
vagina.  The  mammiferse  alone  possess  an  uterus,  but  with  the  ex- 
ception of  that  of  the  monkey,  it  is  very  different  from  the  human 
womb  ;  yet  their  fallopian  tubes  and  ovaries  differ  orily  by  slight 
shades  from  those  of  women.  Almost  all  the  rodentia,  the  rumi- 
nantia,  the  solipedes,  the  amphibia,  &c.  possess  a  womb  divided  into 
three  cavities;  a  middle  one,  which  represents  the  neck,  and  two 
lateral  ones,  called  the  horns,  which  must  not  be  confounded  with 
the  Fallopian  tubes.  These  horns,  or  aduterum,  are  generally  very 
long,  and  sometimes  are  two,  three,  or  four  times  as  long  as  the  cervix, 
which  in  the  Guinea  pig,  the  hare,  &c.  can  scarcely  be  said  to  exist 
at  all.  Hence  it  may  be  said,  that  there  are  in  reality  two  wombs, 
two  tubes,  and  two  ovaries  for  one  single  vagina. 

191.  Separated  in  some  instances  by  a  very  decided  contraction 
from  the  vulva,  and  in  others  continuous,  without  any  line  of  demar- 
cation, with  the  vulva,  sometimes  twice  or  thrice  as  long  as  the  vul- 
var canal,  as  in  the  bitch,  sometimes,  on  the  other  hand  shorter,  as 
in  the  bear,  the  vagina  of  the  mammiferaj  exhibits  numerous  varie- 
ties, in  respect  to  its  dimensions,  the  arrangement  of  its  folds,  and 
its  connexion  with  the  womb. 

But  the  most  remarkable  genital  system  is  that  of  the  didelphic 
or  marsupial  animals :  besides  the  tubes,  their  womb  is  composed 
of  two  horns,  each  of  which  opens  by  an  orifice  furnished  with  a 
valvular  cushion  into  a  third  cavity,  largely  expanded,  of  the  shape 
ofaculdcsac.     This  uul  do  sac  rests  upou  the  vagina,  and  sepa- 


OF  THE  SEXUAL  ORGANS.  75 

rates  it  from  its  horns,  but  does  not  open  into  its  cavity.  It  sends 
off  a  small  canal  which  proceeds  downwards  and  backwards,  then 
mounts  upwards  in  a  semicircular  manner  to  the  orifice  of  the  vagina, 
where  it  opens.  Further,  on  the  lower  part  of  the  belly,  they  have 
a  very  complicated  kind  of  sac,  which  contains  small  teats,  and 
where  their  young  are  deposited  at  a  very  early  period  ;  as  if  for  a 
second  gestation. 

192.  Careful  dissections  of  most  of  the  large  animals  confirm 
what  I  have  now  advanced,  touching  the  nature  of  the  peculiar  tis- 
sue of  the  sexual  organs  of  the  human  female  (168):  the  muscular 
fibres  are  very  evidently  seen  in  the  uterine  horns  of  the  cow,  the 
mare,  «fcc.  where  they  affect  the  same  arrangement  as  the  small  in- 
testines :  the  same  is  true  of  the  cervix,  where  their  direction  is 
chiefly  transversal,  and  of  the  broad  ligaments,  where  they  consti- 
tute several  distinct  bundles. 

§.  VIII.  Difference  according  to  ages. 

193.  In  the  early  periods  of  uterine  life,  the  ovary,  very  large, 
and  particularly  very  much  elongated,  forms  a  sort  of  yellowish  sac, 
which  is  uninterruptedly  continuous  with  the  Fallopian  tube,  as  in 
fishes.  Very  small  in  proportion,  very  slender,  and  almost  lost  in  the 
middle  of  the  broad  ligaments,  it  is  thicker  the  nearer  we  come  to  the 
vagina,  above  which  it  terminates  by  a  neck  that  is  soft,  very  pro- 
jecting, and  of  a  considerable  size  ;  at  the  ninth  month  the  vagina 
is  very  long,  and  wide  enough  to  admit  of  the  introduction  of  the 
finger ;  its  mucous  membrane,  as  well  as  that  of  the  cervix,  is  very 
evident ;  but  the  body  of  the  womb  is  so  firm,  that  it  would  be  diflli- 
cult  to  separate  its  different  tissues.  From  birth  to  puberty  the 
genital  organs  of  the  young  girl  undergo  no  special  change  ;  nothing 
in  them  discloses  the  great  part  they  are  destined  at  some  period  to 
play  in  the  economy,  and  they  merely  follow  in  their  evolution  the 
progress  of  that  of  the  constitution.  At  the  age  of  from  twelve  to 
eighteen  years,  they  awake  from  their  long  stupor.  The  womb 
rapidly  attains  to  double  the  size  it  had  previously  acquired,  both  in 
breadth  and  thickness  ;  the  base  of  the  wedge,  which  it  resembles, 
instead  of  remaining  low  down,  rises  higher  up,  and  thenceforth  the 
woman  commences  a  new  aera.  Although  not  so  marked,  yet  the 
changes  that  take  place  in  the  ovaries  and  Fallopian  tubes  are  not  the 
less  undeniable. 

As  long  as  a  woman  has  had  no  children,  the  genital  organs  re- 
main in  this  state  ;  after  one  or  more  pregnancies,  the  ovaria  become 
covered  with  protuberances,  wrinkles  or  cicatrices,  and  they  still 
increase  a  little  in  size.     The  tubes,  almost  strangers  to  the  great 


76  OF  THE  SEXUAL  ORGANS. 

revolution  operated  in  the  general  system,  scarcely  differ  from  their 
condition  previously  to  the  first  pregnancy,  or  from  what  they  will  be 
at  a  ripe  age,  unless  affected  by  diseases,  of  which  they  often  become 
the  seat ;  the  form  and  proportions  of  the  uterus  remain  unaltered, 
only  it  continues  of  a  rather  increased  size.  The  vagina  becomes 
shorter  and  wider,  while  the  strength  of  the  round  ligaments  is  more 
or  less  augmented.  In  old  age  the  ovaria  are  atrophied,  become 
elongated,  and  of  a  very  irregular  shape ;  the  womb  tends  again 
back  to  its  original  size  ;  the  cavity  of  its  body  becomes  so  contract- 
ed, that  the  stricture  which  connects  it  with  the  neck  is  sometimes 
found  to  close  it  completely  up,  as  has  been  very  judiciously  indicated 
by  M.  Mayer. 

§.  IX.  Anomalies. 

194.  The  anomalous  conditions  of  the  sexual  apparatus,  which 
are  as  numerous  as  they  are  diversified,  all  seem  to  depend  upon  a 
want,  an  arrest,  or  an  aberration  of  development,  or  on  a  disease 
occurring  anteriorly  or  posteriorly  to  the  period  of  birth. 

195.  No  authentic  case  exists  of  a  complete  and  simultaneous 
absence  of  all  the  internal  female  organs  of  generation  ;  but  Chaus- 
sier,  Madame  Boivin,  M.  Duges  and  Cassan,  have  made  mention  of. 
a  person  who  had  only  one  ovary,  one  tube,  and  so  to  speak,  only  one 
half  of  the  uterus.  The  absence  of  the  ovaria  has  been  ascertained, 
in  more  than  one  instance,  although  the  other  parts  of  generation 
were  in  a  natural  state  :  only  one  was  absent  in  the  case  mentioned 
by  M.  Jadelot.  M.  Renauldin  has  seen  them  reduced  to  the  smallest 
possible  size  in  a  woman  about  forty  years  of  age ;  the  Graafian 
vesicles  may  fail  to  become  developed  in  them,  and  that  necessarily 
occasions  sterility. 

1915.  The  tubes  are  rarely  found  wanting,  nor  do  they  often  de- 
viate from  their  ordinary  direction  ;  but  they  occasionally  become 
accidentally  closed,  sometimes  near  the  ovary,  and  at  others  at  a 
point  nearer  to  the  uterus. 

197.  M.  Renauldin  gives  a  very  remarkable  case  of  absence  of 
the  uterus :  the  cervix  alone  existed  in  a  rudimental  state.  This 
fact  is  confirmatory  of  those  previously  reported  by  Bousquct,  The- 
dcn,  Engcl,  Lieutaud,  M.  Caillot,  and  of  the  one  recently  made 
public  by  M.  Breschet.  Sometimes  the  womb  is  very  much  elon- 
gated, as  in  tlie  monkeys ;  it  is  oftener  found  divided  into  two  equal 
or  unequal  portions,  either  partially  or  completely,  internally  or*  only 
externally,  and  sometimes  on  both  surfaces  at  once.  Sometimes 
there  ia  a  sort  of  accidental  sac  superadded  to  the  natural  organ, 
into  which  it  opens,  as  in  th«^  case  related  by  Dionis ;  or,  on  the 


OF  THE  SEXUAL  ORGANS.  77 

contrary,  with  which  it  has  no  communication,  as  in  the  example 
given  by  Canestrini.  Most  generally,  the  division  is  at  tlie  median 
line,  either  externally  and  at  the  fundus,  as  in  one  instance  furnished 
in  the  Leipsic  Commentaries  and  another  related  by  Eisenmann, 
or  on  the  posterior  surface,  as  in  Morgagni's  case,  or  on  the  fundus 
and  both  surfaces  at  the  same  time ;  and  then  the  womb,  really  two- 
horned,  resembles  more  or  less  that  of  the  quadrupeds.  Sometimes 
the  division  comprises  only  the  superior  part  of  the  organ,  which  at 
other  times  is  separated  quite  down,  into  two  portions  ;  sometimes 
the  two  horns  unite  at  an  acute  angle,  and  touch  at  their  corres- 
ponding surfaces  ;  in  other  cases  they  affect  a  transverse  position, 
and  only  unite  at  the  upper  end  of  the  vagina,  so  as  to  form  the  cer- 
vix. Internally,  the  septum  is  also  far  from  being  always  of  the 
same  magnitude.  At  times  it  is  only  a  little  spur  that  divides  the 
fundus  of  the  uterine  cavity  into  two  sinuses,  as  in  the  example  cited 
by  Eisenmann.  In  the  specimen  deposited  at  the  Museum  of  the 
Faculty,  by  M.  Dupuytren,  it  is  simply  represented  by  a  double  me- 
dian crest,  attributable  to  an  hypertrophy  of  the  natural  vertical 
columns  of  the  cavities  of  the  body  and  cervix.  This  septum  may 
stop  at  the  superior  part  of  the  cervix  uteri,  or  descend  as  low  as 
into  the  vagina  ;  it  may  be  complete,  and  divide  the  womb  into  two 
perfectly  distinct  cavities,  or  may  be  pierced  in  some  portion  of  its 
length,  and  allow  one  of  the  cavities  to  communicate  freely  with  the 
other.  The  neck  itself  may  be  single,  as  in  the  instances  related  by 
Bauhin,  Sylvius,  Riolan,  Celti,  Purcell,  Marquet,  Ferlan,  Tiedemann, 
Madame  Boivin  ;  or  double,  as  in  the  cases  of  Grosel,  Mademoseille 
De  la  Marche,  Cruger,  Bartholin,  Haller,  Litre,  De  Tressan,  Eisen- 
mann, Callisen,  Boehmer,  Tiedemann,  MM.  Lallemant,  Dupuytren, 
Dumeril,  Dubois,  West,  Cassan,  Recamier,  Gamier  and  Ollivier 
D' Angers,  and  in  a  case  that  I  saw  in  a  womb,  the  account  of  which 
was  recently  published  by  M.  A.  Berard. 

198.  In  all  these  cases,  the  uterine  orifices  opened  into  a  simple 
or  double  vagina,  according  to  circumstances ;  but  in  a  subject 
dissected  by  Saviard  and  Duvemey,  one  of  them  opened  into  the 
rectum,  while  the  other  maintained  its  natural  disposition.  A  simi- 
lar case  may  be  found  in  the  works  of  Valisnieri ;  at  any  rate,  whe- 
ther the  OS  tinca3  be  simple  or  compound,  whether  it  be  the  termi- 
nation of  a  two  horned  womb,  or  of  one  of  a  perfectly  natural  form, 
it  is  not  extremely  uncommon  to  see  it  terminate  in  the  rectum,  the 
bladder,  or  urethra,  or  even  in  the  hypogastrium,  above  the  pubis. 

199.  Is  it  now  necessary  to  remark  that  the  question  so  long 
debated,  as  to  double  uteri,  resolves  itself  into  a  mere  logomachy  ? 
If  by  double  uterus  we  are  to  understand  the  simultaneous  existence 


78  OF  THE  SEXUAL  ORGANS. 

of  two  wombs,  each  possessed  of  two  tubes  and  two  ovaries,  it  is 
clear  that  none  such  have  been  met  with  ;  if,  on  the  contrary,  to 
constitute  this  condition  it  is  only  necessary  to  have  a  more  or  less 
complete  division  of  the  natural  uterus  into  two  equal  or  unequal 
parts,  each  one  having  its  own  tube,  ovary,  cavity  and  cervix,  there 
are  too  many  examples,  it  is  an  anomaly  too  often  observed,  and  too 
easy  to  be  explained  according  to  the  laws  of  the  animal  economy, 
to  permit  us  to  entertain  the  shadow  of  a  doubt  about  it  at  the  pre- 
sent day. 

200.  The  gestative  organ  is  subject  to  other  irregularities.  M. 
Baudelocque  discovered,  and  had  a  drawing  made  of  a  preternatural 
canal,  which  extended  from  the  right  tube  to  the  cavity  of  the  neck, 
passing  in  the  substance  of  the  parietes  of  the  womb.  Madame 
Boivin  also  makes  mention  of  a  kind  of  irregular  canal  which  seemed 
to  form  a  communication  betwixt  the  ovary  and  the  superior  part  of 
the  vagina  ;  and  perhaps  there  is  no  great  difference  between  this 
anomaly  and  the  canal  mentioned  by  M.  Gartner.  Several  authors 
have  spoken  of  wombs  obliterated  either  wholly,  or  in  part ;  either 
by  a  primitive  faultiness  of  the  development,  or  accidentally ;  the 
cervix  uteri  may  present  a  considerable  length  and  size,  as  in  the 
remarkable  cases  cited  by  Bichat,  MM.  Lallemant,  Segard,  Gar- 
dien,  &c.,  and  its  position  may  be  deranged  by  preternatural  adhe- 
sions, which  fix  one  of  its  faces  or  edges  too  near  the  margin  of  the 
pelvis,  either  in  front,  on  one  side,  or  backwards.  The  ovaries  may 
escape  from  the  pelvis  through  the  openings  at  the  groins,  descend 
into  the  upper  part  of  the  labia  pudendi,  or  pass  over  to  the  side 
opposite  to  that  they  ought  to  occupy,  and  become  entangled  with 
the  tubes  in  such  a  manner  as  to  be  extricated  with  difficulty,  as  in 
a  case  that  fell  under  my  own  notice. 

201.  Vicious  conformations  of  the  vagina  are  not  less  frequent 
than  those  of  the  womb.  Its  total  absence  is  pretty  common.  MM. 
Boyer,  Caillot,  Willaume,  and  an  infinity  of  others,  have  seen  it  ter- 
minate in  a  cul  de  sac  above  the  vulva,  and  not  open  externally 
at  all ;  in  some  cases  its  vulvar  opening  exists,  but  is  obliterated 
above,  and  does  not  extend  to  the  uterus.  All  the  students  of  the 
school  of  Paris  may  have  seen  a  woman  of  this  conformation  a  few 
months  since  in  the  wards  of  the  IIotel-Dieu.  I  have  observed  a 
similar  disposition  in  a  woman  of  about  thirty  years  of  age,  who  had 
been  delivered  of  a  child  five  years  previously,  and  had  not  had  her 
menses  since  that  period.  In  M.  Sue's  case  the  rectum  opened 
into  the  vagina,  and  the  vagina  into  the  bladder  ;  nevertheless,  the 
vulvo-utcrine  passage  may  open  into  the  bladder  of  urine,  without 
the  bowel  being  at  all  deviated  from  its  natural  course,  as  is  proved 


OF  THE  SEXUAL  ORGANS.  79 

in  the  cases  related  by  Maret,Palfin  and  Cassan  ;  the  vagina  is  more 
frequently  found  to  terminate  in  the  rectum,  at  various  distances 
from  the  anus.  The  septum  which  divides  it  is  pretty  often  com- 
posed either  of  a  simple  fr;Enum,  connate  or  accidental,  situated 
transversely,  or  parallel  to  its  axis,  near  the  vulva  or  cervix,  or 
towards  the  .middle  of  the  canal;  or,  of  a  valvular  fold,  more  or  less 
strong  ;  or,  of  a  real  diaphragm.  I  .have  observed  all  these  differ- 
ences both  in  the  living  and  dead  subject.  This  septum  may  give 
to  the  vagina  the  appearance  of  two  united  cylindrical  canals,  each 
having  a  hymen,  as  occurred  twice  to  Callisen  and  once  to  Eisen- 
mann,  or  a  single  external  opening,  as  noticed  by  Bartholin  and  Hal- 
ler  ;  sometimes  it  exists  only  above  and  below,  and  allows  the  two 
vaginje  to  communicate  with  each  other,  about  their  middle  or  near 
the  neck ;  most  frequently,  as  remarked  by  Majocchi,  Bcehmer, 
Cassan,  &c.,  it  does  not  reach  to  the  vulva,  and  further,  is  in  general 
only  the  continuation  of  a  similar  disposition  of  the  womb. 

202.  If  such  observations  were  good  for  nothing  but  to  satisfy  an 
idle  curiosity,  I  should  not  have  dwelt  so  long  on  them  ;  but  many 
of  them  are  closely  concerned  with  the  practice  of  tokology  ;  others 
explain  several  phenomena,  of  which  it  would  be  otherwise  difficult 
to  give  any  account :  sterility,  several  kinds  of  extra-uterine  preg- 
nancy, superfetation,  retention  of  the  menses,  fecundation  and  de- 
livery through  the  anus,  and  want  of  menstruation,  are  cases  in 
point.  When  the  womb  is  double,  if  the  woman  becomes  preg- 
nant in  one  side  only,  and  there  are,  meanwhile,  two  orifices,  quite 
separate  from  each  other  in  the  vagina,  two  different  persons,  al- 
though equally  learned,  may  establish  a  very  different  diagnosis, 
even  during  labour.  Two  distinguished  physicians,  says  Tiedemann, 
met  together  to  see  a  woman  who  supposed  herself  on  the  point  of 
lying  in ;  having  touched  her,  one  declared  that  the  neck  was  in  a 
natural  state ;  the  other  found  it  dilated,  and  said  that  the  head  was 
engaged.  Another  examination  showed  them  that  the  neck  was 
double.  M.  West  laid  before  the  Academy  of  Medicine  a  nearly 
similar  case,  collected  at  the  Matemite  of  Paris  :  at  the  commence- 
ment of  the  labour  one  of  the  pupils  not  only  thought  that  dilata- 
tion had  not  begun,  but  that  the  neck  was  not  quite  effaced  ;  the 
other  found  it  dilated  nearly  one  inch ;  the  woman  having  died  in 
labour,  the  post  mortem  examination  showed  the  reason  of  this  dif- 
ference of  opinion  ;  the  womb,  which  was  double,  terminated  by  a 
double  OS  tincae  in  the  vagina. 

203.  If  by  imagining  laws  we  could  compel  nature  to  obey  them, 
I  should  be  content  to  say  with  Tiedemann  and  Meckel,  that  a  ma- 


80  OF  THE  SEXUAL  ORGANS. 

* 

jority  of  the  irregular  conformations  of  the  genitalia  are  only  in- 
stances of  a  persistence  of  their  primitive,  but  natural  state  of  organ- 
ization ;  that  the  uterus  bicornis,  for  example,  depends  upon  this,  that 
the  two  half  cylinders  which  are  said  to.constitute  its  first  rudiments, 
have  disobeyed  the  laws  of  conjunction  discovered  by  M.  Serres: 
but,  unfortunately,  it  happens  in  this  as  in  most  other  cases,  the  mo- 
tives, the  causes  escape  our  research,  and  these  brilliant  concep- 
tions have  but  one  fault,  and  that  is  they  do  not  agree  with  actual 
observation.  I  am  bold  to  affirm,  from  numerous  researches,  that 
the  womb  and  vagina  in  reality  present  from  their  very  first  appear- 
ance, the  same  £orm  and  the  same  general  characters,  as  tliose  they 
possess  after  their  complete  development. 

§.  X.  Hermaphrodism. 

204.  A  being  in  whom  two  se.xes  are  united  is  called  an  herma- 
phrodite; this  name,  according  to  fable,  is  derived  from  Hermaphro- 
dite, the  son  of  Mercury  (£§/«»£)  and  Venus  (A(p5o«r/T«c^,  who  was 
condemned  by  the  gods  to  unite  his  body  to  that  of  Salmacis,  for 
having  despised  the  charms  of  that  nymph.  Often  debated  in  the 
courts  of  justice  in  times  past,  and  by  the  physiologists  of  all  ages, 
the  question  of  hermaphrodism  or  androgyny,  almost  wholly  aban- 
doned towards  the  close  of  the  last  century,  seems  on  the  point  of 
coming  up  again  to  divide  the  opinions  of  the  learned.  In  the  mo- 
noecious plants,  in  zoophytes,  and  various  molusca,  such  as  the  oys- 
ter and  snail,  the  two  germs  are  found  to  exist  in  the  same  indivi- 
dual ;  but  the  sexes  are  observed  to  be  separate  in  the  dioecious 
vegetables,  and  in  the  animal  kingdom,  in  worms,-  insects,  and  also 
in  fishes,  reptiles,  birds,  and  mammiferous  animals.  So  that  her- 
maphrodism in  the  human  species  is,  at  least  to  all  appearance, 
contrary  to  those  laws  that  preside  over  the  grand  distinctions  of 
living  beings.  Notwithstanding  this,  M.  Tiedemann,  setting  out  on 
the  principle  that  the  embryo  is  at  the  beginning  neither  male  nor 
female,  admits  the  possibility  of  hermaphrodism,  and  his  opinion  is 
maintained  in  Germany  by  M.  Meckel  and  several  other  pliysiolo- 
gists.  It  is  true  that  a  strange  assemblage  of  organs  has  been  fre- 
quently noticed,  which,  though  in  the  same  subject,  appeared  to 
belong  to  different  sexes.;  but  all  cases  of  this  sort,  when  divested 
of  the  marvellous  with  which  ignorance  or  the  love  of  the  marvel- 
lous has  clothed  them,  may  be  easily  classed  with  some  kind  of 
monstrosity  of  one  or  the  other  of  the  sexes.  No  individual  has 
ever  been  seen  to  possess  both  the  male  and  female  genital  organs. 
On  .some  occasions  an  enormous  clitoris  has  induced  the  belief  that 
the  individual  was  at  once  male  and  female,  and,  like  some  of  the 


OF  THE  SEXUAL  ORGANS.  81 

gasteropoda,  capable  both  of  fecundating  and  being  fecundated. 
Sometimes  it  is  a  slightly  developed  penis,  an  hypospadiaeos,  a  slit  in 
the  scrotum,  that  have  been  mistaken  for  a  vulva  and  clitoris,  as  in 
the  case  recently  presented  to  the  Academy  by  M.  RuUier,  and 
that  which  all  the  physicians  in  Paris  may  have  had  an  oppor- 
tunity to  examine  in  a  man  who  exhibited  himself  for  a  long  time 
here  to  the  public.  At  other  times  it  is  either  a  pi-olapsion  or  a  pro- 
longation of  the  cervix  uteri  which  inexperienced  observers  have 
mistaken  for  a  penis,  as  happened  with  the  judges  of  Toulouse  in 
the  famous  affair  of  Margaret  Malaure. 

In  certain  cases,  however,  one  might  be  considerably  embarrassed 
in  forming  an  opinion :  a  person  who  possessed  all  the  external 
characters  of  a  pretty  woman,  presented  herself  to  M.  Marjolin,  and 
begged  him  to  examine  her  and  inform  her  to  which  sex  she  be- 
longed :  in  the  labia  of  a  pretty  well  formed  vulva,  the  professor 
felt  two  oblong  tuniours,  which  were  of  the  size  of  the  male  tes- 
ticles ;  there  was  a  vagina  which  terminated  in  a  blind  sac  behind 
the  pubis,  and  the  bladder  opened  under  the  root  of  a  body,  which 
bore  a  much  stronger  resemblance  to  the  penis  than  to  the  clitoris. 
Professor  Mayer  dissected  a  child  six  months  old,  that  had  no  vulva, 
but  a  penis  perforated  with  an  urethra,  and  on  the  sides  of  which 
were  observed  two  small  roundish  tumours  inclosed  in  a  fold  of  skin, 
and  yet  it  had  an  uterus. 

205.  I  think,  without,  however,  being  able  to  affirm  it,  that  the 
person  examined  by  M.  Marjolin  was  a  female,  with  congenital  her- 
nia of  the  ovaries  and  preternatural  development  of  the  clitoris ; 
M.  Mayer's  case  was  certainly  a  girl,  also  affected  with  hernia  of 
the  ovaries,  and  whose  vagina  opening  into  the  bladder,  was  con- 
tinuous with  the  urethra. 

206.  It  may  therefore  be  admitted,  agreeably  to  the  sentiments  of 
M.  Marc,  that  hermaphrodism  is  only  apparent,  and  its  species  may 
be  divided  into  three  genera  :  one  in  which  there  is  monstrosity  in  the 
male  ;  the  second,  in  which  the  feminine  sex  cannot  be  mistaken  ; 
and  the  third,  in  which  it  is  not  so  easy  to  characterise  the  individual. 
The  Memoirs  of  the  Academy  of  Sciences,  those  of  the  Academy  of 
Dijon,  the  Philosophical  Transactions,  the  Bulletins  of  the  Faculty 
of  Medicine  of  Paris,  a  Memoir  by  M.  Pierquin,  almost  all  the  sci- 
entific collections,  a  work  by  the  learned  German  professor  Bur- 
dach,  contain  numerous  cases  more  or  less  analogous  to  those  I  have 
above  analyzed. 

L 


82 


CHAPTER  II. 

Functions  of  the  Sexual  Organs. 

ARTICLE  I. 
Of  Menstruation^  or  the  Catamenial  Discharge. 

207.  Puberty,  or  the  marriageable  age,  is  announced  in  girls,  as 
it  is  in  boys,  by  numerous  changes.  The  general  organization, 
which,  until  that  period,  had  progressed  alike  in  both  beings,  seems 
suddenly  to  take  an  opposite  direction  in  each.  The  young  girl  be- 
comes more  timid  and  reserved  ;  her  form  becomes  more  rounded, 
her  voice  alters,  but  to  take  on  a  softer  and  more  harmonious  tone  ; 
her  bosom  is  developed  ;  the  cellular  tissue  extends  from  the  front 
of  the  breast  and  the  hypogastrium,  as  from  two  centres,  towards  the 
neck,  while  it  at  the  same  time  proceeds  to  form  a  soft  cushion  for 
the  upper  part  of  the  limbs.  Her  eyes,  which  are  at  once  brilliant 
and  languishing,  express  commingled  desires,  fears,  and  tenderness  ; 
the  sensations  she  experiences,  and  the  sense  of  her  own  weakness, 
are  the  causes  why  she  no  longer  dares  to  approach  the  companions 
of  her  childhood  but  with  a  downcast  look.  On  the  other  hand,  the 
gentle  modesty  that  animates  her  countenance,  and  the  seductive 
graces  of  her  demeanour,  soon  disclose  a  power  whose  existence 
she  never  suspected,  and  which  renders  it  true  to  say  that  the  mar- 
riageable age  in  the  softer  sex  is  the  spring  tide  of  nature  and  the 
season  of  the  pleasures  ;  but  a  new  function,  the  catamenial,  the  abso- 
lute compass  of  good  or  bad  health  in  women,  is  established  with 
more  or  less  difficulty  in  the  midst  of  this  great  revolution,  and  by 
the  disorders  or  accidents  which  it  involves,  sometimes  dashes  with 
bitterness  those  happy  seasons  to  which  it  should  naturally  serve,  as 
the  prelude. 

208.  Definilum.  Menstruation  consists  in  a  sanguineous  dis- 
charge from  the  sexual  parts.  It  is  a  natural  function,  to  which 
women  have  in  all  ages  of  the  world  been  subject.     The  supposi- 


OF  MENSTRUATION.  83 

tions  of  Emmet,  of  Roussel,  of  M.  Aubert,  &c.  who  think  that  the 
menses  are  the  result  of  civilization,  appear  to  me  wholly  unfounded. 
Neither  is  it  true  that  the  women  of  the  arctic  pole,  the  aborigines  of 
Brazil,  and  of  some  other  countries  in  America,  are  exempt  from 
them.  Nothing,  however,  of  the  kind  exists  in  animals,  with  the 
exception  of  the  ourang-outang,  some  of  the  monkeys,  and  the  bat, 
which,  according  to  some  naturalists,  are  subject  to  a  periodical  dis- 
charge. If,  in  other  species,  such  as  the  quadrupeds,  the  cetaceae, 
birds,  &.C.  we  sometimes  find  that  a  coloured  mucus  escapes  from 
the  cloaca  or  vulva,  it  will  be,  in  general,  only  at  the  approach  of  the 
season  for  copulation,  and  it  would  be  unreasonable  to  compare  this 
phenomenon  with  the  function  of  menstruation. 

209.  The  menses,  still  known  among  tlie  common  people  as  the 
regies^*  lunes,  mois,  jleurs  or  jlueurs^  purgation.,  affaires.,  and  epo- 
ques,  appear  at  puberty,  and  cease  with  fecundity,  during  pregnancy, 
and  while  the  woman  gives  suck.  As  soon  as  they  appear,  fecunda- 
tion is  possible,  and  as  long  as  they  continue  to  return  at  the  natural 
period,  we  may  conclude  that  the  woman  has  not  conceived.  Ob- 
servers have  often  made  mention  of  women  who  were  not  regulated, 
and  had  never  been  so,  but  who  enjoyed,  nevertheless,  a  good  state 
of  health ;  it  is  to  be  observed,  however,  as  remarked  by  Linnasus, 
that  they  were  sterile.  I  am  acquainted  with  a  lady  who  is  not  re- 
gulated, ruddy,  and  of  a  good  size,  in  blooming  health,  married  for 
ten  years,  whose  greatest  desire  is  to  become  a  mother,  but  who  has 
lost  all  hope  of  becoming  so  ;  her  husband,  moreover,  is  young,  loves 
her  tenderly,  and  before  he  married  her  had  begotten  a  child  by  an- 
other woman.  I  have  seen  another  at  the  hospital  of  Tours,  who 
had  never  seen  any  thing.,  as  she  expressed  it,  but  who,  notwith- 
standing, was  the  mother  of  a  strong  and  healthy  son  of  fifteen  or 
eighteen  years  of  age.  It  seems  to  me  to  be  almost  certain  that 
the  absence  of  the  menses  generally  depends  upon  some  faulty  con- 
formation of  the  womb  or  its  appendages  ;  so  that  it  may  be  easily 
conceived  that  it  is  generally  a  sign  of  sterility.  Deventerand  Bau- 
delocque  have  known  women  who  were  never  regular  except  during 
pregnancy,  and  I  have  collected  several  similar  cases. 

210.  Eruption.  In  our  temperate  climes  the  menses  commence 
between  the  twelfth  and  sixteenth  year ;  a  httle  earlier,  from  eight 
to  twelve  years,  in  southern  climates  ;  and  a  little  later,  from  fifteen 
to  twenty  years,  in  the  north.     Some  travellers  even  pretend  that  the 

*  I  have  left  the  French  terms  in  this  place  untranslated,  for  they  are  unsus- 
ceptible of  translation.  I  have  preferred  to  give  in  a  note  the  English  names  in 
common  use.  They  are  menses,  flowers,  monthly  discharge,  show,  regular  dis- 
charge, monthlys,  time,  and  most  commonly  they  arc  alluded  to  with  a  nod.    M. 


84  OF  MENSTRUATION. 

Turkish  women  are  capable  of  becoming  mothers  at  the  age  of  seven 
or  eight  years,  Dr  Prideaux,  for  example,  relates  that  Cadijah^ 
aged  five  years,  was  regular  when  Mahomet  espoused  her.  But 
this  story,  like  most  others  that  come  from  countries  of  whose  man- 
ners and  customs  we  know  so  little,  is  only  a  popular  tale,  for  I 
find  in  a  faithful  translation  of  the  Koran,  that  Cadijah  was  upwards 
of  forty  years  old  when  she  married  the  prophet.  Others  tell  us, 
that  near  the  poles,  and  on  the  northern  slopes  of  mountains,  it  is 
not  uncommon  for  the  menses  not  to  appear  until  the  twenty-third 
or  twenty-fourth  year. 

211.  The  discrepancies  presented  by  opposite  climates  in  mass, 
is  found  to  be  true  in  the  details  in  every  country,  and  occasionally 
in  every  province  and  city.  A  country  life  and  occupations,  sim- 
plicity of  manners,  a  frugal  regimen,  like  the  temperature  of  northern 
regions,  procrastinate  the  first  menstrual  epoch  ;  a  life  of  leisure,  the 
imitative  arts,  such  as  painting  and  music,  the  habit  of  frequenting 
balls,  the  theatre,  lascivious  books  and  pictures,  good  living,  the  use 
of  stimulating  drinks,  and  living  in  populous  cities,  tend  on  the  other 
hand,  like  the  temperature  of  the  equatorial  latitudes,  to  accelerate  its 
appearance.  It  is  less  precocious  also  in  a  robust  woman,  of  a 
lymphatico-sanguine  temperament,  very  fat,  and  whose  Sensibility  is 
not  very  acute,  than  in  those  who  are  thin,  delicate,  nervous,  irri- 
table and  sanguine.  Even  at  Paris,  girls  are  occasionally  observed 
to  become  regular  at  ten,  eleven  and  twelve  years :  I  know  two  who 
were  so,  one  at  nine  and  a  half,  and  the  other  at  ten  and  a  half  years ; 
and  I  am  in  the  habit  of  visiting  a  family  where  the  young  lady,  who  at 
fourteen,  is  as  tall  and  robust  as  a  majority  of  women  at  twenty,  has 
been  entirely  in  a  state  of  puberty  since  she  was  eight  years  and  a 
half  old.  Children  are  also  spoken  of  who  were  regular  at  birth,  or 
between  the  first  and  fifth  year  of  their  age,  but  it  is  reasonable  to 
suppose  that  this  discharge  must  have  been  owing  to  some  disease, 
or  at  least  had  nothing  in  common  with  the  catamenial  flow.  On 
this  subject  I  cannot  however  withhold  a  case  recently  made  public; 
it  is  that  of  a  young  girl  at  Havannah,  whose  menses  appeared  first 
when  she  was  eighteen  months  old,  and  have  since  that  continued  to 
return  once  a  month ;  the  child,  moreover,  has  a  bosom,  a  very  de- 
cided character  of  countenance,  and  all  the  marks  of  anticipated 
puberty.  Other  persons  also  are  seen  at  this  capital,  who  did  not 
menstruate  until  their  seventeenth,  eighteenth,  nineteenth,  or  twen- 
tieth years.  Osiander  noticed  at  Gottingen,  that  of  one  hundred 
and  thirty-seven  women,  nine  became  regular  at  twelve  years  of 
age,  eight  at  thirteen,  twenty-one  at  fourteen,  thirty-two  at  fifteen, 
twenty-four  at  sixteen,  eleven  at  seventeen,  eighteen  at  eighteen,  ten 


OF  MENSTRUATION.  85 

at  nineteen,  eight  at  twenty,  one  at  twenty-one,  and  one  other  at 
twenty-four  years  of  age. 

Preceded,  commonly,  by  a  sense  of  general  lassitude,  of  uneasiness 
in  the  limbs,  of  weight  in  the  loins,  of  heat,  of  tension  in  the  epigas- 
trium and  perineum,  by  a  slight  pruritus  of  the  sexual  parts,  by  a  mu- 
cous discharge,  that  is  clear  or  yellow,  and  more  or  less  abundant,  it 
happens  also  that  the  first  eruption  of  the  menses  is  in  many  women 
effected  without  its  being  announced  by  any  precursory  symptoms  ;  it 
is  then  rarely  abundant,  nor  does  it  commonly  last  more  than  two  or 
three  days.  In  general  they  do  not  become  regular  until  after  three 
or  four  periods  ;  in  the  succeeding  appearances,  the  discharge  lasts 
variously  from  a  few  hours  to  a  week,  but  the  average  term  is  four 
or  five  days. 

212.  The  quantity  of  blood  that  escapes  amounts,  according  to 
Hippocrates,  to  two  cotyliE,  or  to  eighteen  ounces  according  to 
Galen.  Haller  computes  it  at  six,  eight,  or  twelve  ounces,  and  Bau- 
delocque  at  only  three  or  four  ounces ;  in  general  it  is  more  profuse 
in  persons  and  places  where  its  appearance  is  most  precocious,  so 
that  European  women  who  go  to  inhabit  a  warm  climate,  as  for 
example  Batavia  or  Java,  often  perish  in  consequence  of  their  pro- 
fuse menstrual  evacuations.  M.  Desormeaux  has  remarked,  and  I 
have  also  had  occasion  to  observe  it,  that  country  girls  who  come  to 
Paris  to  go  to  service,  not  unfrequently  find  that  their  menses  are 
stopped  or  considerably  diminished.  As  the  different  periods  are 
not  always  alike  in  the  same  woman,  as  they  are  sometimes  more 
abundant  or  less  so  every  second  or  third  period,  alternately,  it 
is  impossible  to  have  any  certain  data  on  this  subject.  Again,  as 
the  blood  that  flows  from  the  organs  can  only  be  collected  on  cloths 
or  in  water,  it  is  manifest  the  observer  must  frequently  make  up  an 
erroneous  opinion,  and  that  he  ought  to  count  upon  obtaining  merely 
approximative  results. 

213.  Nature.  The  minds  of  the  ancient  physiologists  were 
strongly  exercised  in  regard  to  the  catamenial  blood.  It  is  similar, 
says  Hippocrates,  to  that  of  a  slaughtered  animal ;  or  again,  accord- 
ing to  Aristotle,  to  that  which  flows  from  a  simple  wound.  There 
are  now  but  few  opponents  of  this  system  among  medical  men.  But 
very  different  ideas  prevailed  at  Rome  in  the  time  of  Pliny,  and  are 
still  very  commonly  upheld  among  the  public.  If  we  might  believe 
the  celebrated  Roman  naturalist,  the  menstrual  fluid,  endowed  with 
the  most  noxious  qualities,  would  be  considered  as  a  dangerous  poison, 
whose  exhalations  alone  are  suflScient  to  turn  all  the  sauces  of  a  whole 
kitchen,  the  cheeses  of  a  whole  dairy,  to  make  a  whole  family  sick,  and 
wilt  all  the  flowers  of  a  parterre  ;  travellers  inform  us  that  even  now, 


86  OF  MENSTRUATION. 

in  some  parts  of  America,  women  are  so  much  dreaded  during  their 
menstrual  periods,  that  they  are  forbidden  to  go  out  of  doors  except 
in  cases  of  urgent  necessity ;  and  further,  that  they  are  obliged  to 
wear  a  mark  that  advertises  people  of  their  situation,  so  that  they 
may  flee  out  of  their  way.  While  ridiculing,  as  they  deserve,  such 
fables  as  these,  the  moderns  have  perhaps  too  much  neglected  that 
portion  which  may  be  true.  It  is  very  rarely  that  a  vulgar  prejudice 
does  not  contain  some  truth.  If  we  reflect  on  the  odour  derived 
from  the  different  secretions  of  animals,  or  the  aroma  exhaled  from 
the  skin  of  certain  women,  is  it  fair  to  reject  without  distinction  all 
that  has  been  said  in  relation  to  the  menstrual  excretion  ?  I  am 
certainly  far  from  giving  credit  to  the  peculiarities  related  by  Pliny, 
Columella  and  the  Arabians ;  but  I  do  not  see  why  the  miasms  that 
escape  from  a  female  during  the  flow  of  her  menses,  should  be  in- 
capable of  turning  a  fluid  so  easily  affected  as  milk,  nor  why  it  could 
not  possibly  have  the  same  effect  on  certain  sauces.  Besides,  it  is 
evident  that  blood  retained  for  some  time  within  the  sexual  organs, 
particularly  of  women  who  are  inattentive  to  cleanliness,  may,  by 
being  decomposed,  acquire  certain  deleterious  properties. 

Its  odour  is  too  variable  to  permit  us  to  compare  it  to  the  marigold, 
rather  than  to  any  thing  else.  From  its  being  found  fluid,  although 
long  retained  in  the  womb,  we  are  not  authorised  to  conclude  with 
M.  Lavagna,  that  it  contains  no  fibrine ;  we  too  frequently  see  it 
escape  in  clots  from  women  who  get  up  to  walk  about  after  having 
bsen  long  in  a  sitting  posture,  to  be  able  to  say  with  Dionis,  that 
menstrual  blood  never  coagulates.  According  to  all  appearances, 
it  contains  less  fibrine  than  that  from  other  parts  of  the  body,  but  is  not 
entirely  without  it.  Being  mixed  with  the  mucous  and  serous  mat- 
ters naturally  furnished  by  the  internal  surface  of  the  genital  organs, 
the  menstrual  blood  is  thus  rendered  more  viscous,  and  ought  not  to 
exhibit  the  same  characters  as  that  which  escapes  from  a  wound. 

214.  Progress.  The  menstrual  fluid  is,  in  most  women,  at  first 
very  liquid,  serous,  scanty,  and  not  high  coloured  ;  its  consistence 
and  quantity  increase  on  the  second  day  ;  on  the  third  it  is  in  almost 
every  respect  similar  to  the  blood  that  escapes  from  the  nose  in 
epistaxis ;  the  fourth  restores  to  it  the  characters  of  the  second,  and 
on  the  fifth  its  appearances  are  analogous  to  those  of  the  first ;  some- 
times, on  the  contrary,  the  evacuation  has  a  slower  course,  and  is 
not  really  abundant  until  the  fourth  or  fifth,  while  in  others  the  blood 
flows  from  the  commencement  in  as  great  a  quantity  as  on  the  second 
or  third  days.  In  some  cases  it  appears  one  day,  does  not  return 
the  next,  and  flows  in  abundance  afterwards.  It  most  commonly 
comes  away  in  the  shape  of  simple  small  drops,  which  flow  fast. 


OF  MENSTRUATION.  87 

and  some  women  are  obliged  to  be  very  careful  to  prevent  it  from 
falling  in  quantities  to  the  ground. 

215.  The  periodical  return  of  the  menses  ordinarily  takes  place 
every  month,  as  their  name  indicates,  or  rather  every-twenty-eight  or 
twenty-nine  days,  which  brings  them  into  relation  with  the  lunar 
periods  ;  in  an  infinity  of  people  they  are  observed  to  recur  at  nearer 
or  remoter  periods  ;  sometimes  only  twenty-two,  twenty,  eighteen, 
and  even  fifteen  days  elapse  between  each  catamenial  revolution  ;  I 
know  a  person  who  is  never  more  than  twelve  days  free  from  it ; 
and  I  have  the  care  of  another  who  is  almost  always  affected  with  it, 
but  who  in  other  respects  is  in  good  health,  only  she  is  thin,  and  of 
an  extreme  sensibility.  These  frequent  returns  of  the  menses,  with- 
out any  peculiar  change  in  the  health,  are  particularly  to  be  ob- 
served in  warm  countries,  and  in  nervous  women.  The  emaciation 
which  attends  this  state  is  at  the  critical  period  frequently  succeeded 
by  plumpness  more  or  less  decided,  as  if  the  sanguine  discharges  to 
which  nature  had  become  accustomed  were  now  turned  to  the 
benefit  of  the  whole  organism  ! 

Others  are  regular  every  thirty-second,  thirty-fifth,  or  fortieth  day, 
and  even  every  two  or  three  months,  without  being  in  the  least  in- 
commoded, as  is  pretty  frequently  observed  to  be  the  case  in  Green- 
land, Lapland  and  other  cold  countries  ;  and  neither  is  it  uncommon 
to  observe  the  same  thing  in  our  own  country  places  ;  but  none  of 
these  anomalies  contradict  the  principles  established  by  physiolo- 
gists in  all  ages. 

216.  Without  daring  to  set  up  the  simple  results  of  my  own  ob- 
servations, in  opposition  to  those  who  assert  that  all  women  are 
regular  in  the  first  fortnight  of  the  month,  half  from  the  first  to  the 
eighth,  and  the  rest  from  the  eighth  to  the  fifteenth,  I  cannot  refrain 
from  stating  that  I  have  seen  as  many  who  were  menstruating  at 
the  close  as  at  the  beginning  of  each  month  in  the  year  ;  I  therefore 
do  not  believe  it  possible  to  establish  any  thing  certain  on  this  head. 

217.  Causes.  Physiologists  have  been  for  a  long  time  divided  in 
regard  to  the  causes  of  menstruation,  and  at  the  present  day  even, 
every  thing  seems  to  indicate  that  there  will  not  be  a  unity  of  senti- 
ment very  soon  on  this  point.  Some  authors  have  stated,  with  Aris- 
totle and  Galen,  Simson,  Astruc,  and  M.  Lobstein,  that  the  menses 
depend  upon  a  general  or  local  plethora,  upon  a  superabundance  of 
blood:  others,  with  Osiander,  pretend  that  the  menses  are  occasion- 
ed by  too  large  a  proportion  of  carbon  and  azote  being  contained  in 
the  blood  of  the  uterus.  Dr  Clifton  refers  them  to  the  relative 
weakness  of  the  venous  parietes,  and  to  the  perpendicular  effort  of 


88  OF  MENSTRUATION. 

the  blood.  Paracelsus,  Sylvius,  and  De  Graaf  think  they  are  pro- 
duced by  a  principle  of  fermentation  ;  Stahl  and  M.  Duges  suppose 
they  arise  under  the  influence  of  an  irritamentum  or  peculiar  moli- 
men;  Emmett,  who  attributes  them  to  an  erection,  and  Lecat,  who 
qualifies  them  as  an  amorous  phlogosis,  suppose  them  to  be  the 
effect  of  venereal  desires.  But  who  does  not  herein  perceive  that 
vain  show  of  words  so  prodigally  made  use  of  in  ancient  physiology, 
or,  that  such  suppositions  as  these  only  serve  to  protract,  without 
solving  the  problem  ? 

218.  The  periodicity  of  the  menses  has  not  been  explained  any 
better  than  their  general  cause.  Aristotle,  Vanhelmont,  Mead,  and 
even  our  elegant  Roussel,  attributed  it  to  the  influence  of  the  moon. 
From  the  physicians,  this  opinion  has  passed  among  the  people,  and 
the  poets  have  converted  it  into  a  proverb  by  the  following  verse : 

Luna  vetus  tetulas,  juvenes  nova  luna  repurgat. 

But  to  show  its  fallacy,  we  need  only  recollect  that  the  same 
woman  may  be  regular  at  different  lunar  phases,  once  in  the  space 
of  several,  or  even  of  one  single  year  ;  however,  this  is  a  point  on 
which  there  is  need  for  new  researches,  and  for  the  completie  clear- 
ing up  of  which,  numerous  observations  would  be  required. 

219.  Many  attempts  have  been  also  made  with  the  view  to  ascer- 
tain the  final  causes  of  menstruation,  but  it  must  be  confessed  with 
equally  ill  success.  What  in  fact  is  proved  by  saying  that  this  func- 
tion disposes  and  maintains  the  uterus  in  a  state  apt  for  fecundation; 
that  its  suppression  during  pregnancy  permits  the  ovum  to  grow  and 
be  developed  without  weakening  the  female  ?  It  is  generally  quite 
well  known  that  conception  does  not  take  place  until  the  menses 
have  appeared,  nor  after  they  have  ceased  to  return  ;  but  the  why 
and  the  how  are  not  known  :  they  are  the  sign  and  not  the  cause  of 
fecundity  ;  the  absence  of  the  menses  does  not  produce  sterility  ;  but 
women  who  do  not  menstruate,  are  often  found  to  be  sterile,  because, 
in  either  case,  something  is  wrong  in  the  state  of  the  genital  organs. 

220.  Seat.  The  seat  of  the  menstrual  discharge  is  another  sub- 
ject on  which  the  naturalists  continue  still  to  dispute.  The  Greeks, 
the  Arabians,  and  a  majority  of  writers  of  all  ages  place  it  in  the  ute- 
rus ;  but  Columbus,  Severiu  Pineau,  Bohn,  as  well  as  a  crowd  of 
moderns,  and  among  them  M.  Dcsormeaux,  have  seen  the  menses 
escaping  immediately  from  the  vagina,  or  the  different  parts  which 
constitute  the  vulva  ;  the  uterus,  it  is  said,  cannot  furnish  them  when 
they  flow  during  pregnancy. 

221.  It  appears  to  me  to  be  easy  to  reconcile  these  opinions. 
The  blood  of  the  menses  undeniably  comes  from  the  uterine  cavity 


OF  MENSTRUATION.  89 

in  the  majority  of  instances ;  facts  the  most  multiplied  and  authentic 
prove  it  incontestably.  Thus,  in  persons  whose  menses  had  been 
long  suppressed,  in  consequence  of  disease,  or  had  never  appeared, 
in  consequence  of  some  faulty  organization  of  the  vagina  or  vulva, 
the  womb  has  an  hundred  times  been  found  full  and  distended  with 
blood  5  in  others  who  died  while  menstruating,  the  cavity  of  the 
womb  has  been  seen  covered  with  ecchymoses,  and  sometimes  filled 
with  clots  of  blood.  If  the  os  tincse  be  confined  in  the  cupule  of  a 
pessary  with  a  cylindrical  opening  passing  through  it,  the  blood  will 
be  found  to  escape  therefrom  ;  when  there  is  a  prolapsus,  it  may  be 
seen  distilling  from  the  cervix  ;  and  in  the  natural  state,  we  find  by 
placing  the  finger  between  the  lips  of  the  os  tincae,  that  the  fluid 
escapes  from  the  part. 

222.  On  the  other  hand  it  is  equally  certain  that  it  has  sometimes 
been  seen  to  exude  from  the  interior  of  the  vagina  or  vulva ;  I 
do  not  perceive,  indeed,  how  it  can  be  otherwise  in  a  woman  who 
continues  to  menstruate  during  her  whole  gestation.  But  these  cases 
are  exceptions,  anomalies,  and  do  not  invalidate  the  general  rule : 
menstruation  is  then  deviated  from  its  general  route,  as  is  the  case 
when  it  takes  place  from  the  urethra,  the  rectum,  the  pulmonary 
passages,  the  breasts,  or  some  portion  of  the  tegumentary  surfaces. 
These  irregularities,  moreover,  are  rare,  and  appear  to  have  been 
in  more  than  one  instance  the  effect  of  real  disease. 

223.  Source.  Attempts  have  been  made,  also,  to  ascertain  the 
immediate  source  of  the  menses,  one  party  placing  it  in  the  veins, 
along  with  Vesalius,  in  the  arteries,  with  Ruysch,  or  the  capillaries, 
with  Winslaw  and'Meibomius  ;  others  think  it  is  to  be  found  in  cer- 
tain particular  gRindules,  as  Lister,  or  in  peculiar  little  receptacles, 
as  Simson,  or  lastly,  with  Astruc,  in  a  supposed  set  of  venous  sinu- 
ses. There  are  as  many  gratuitous  suppositions  as  there  are  opi- 
nions, all  of  them  referring  to  a  question  as  idle  as  it  is  difficult  of 
solution.  The  menstrual  blood  escapes  from  the  womb  by  exhala- 
tion or  by  perspiration,  as  in  all  the  hemorrhagies  of  the  mucous 
membranes,  but  without  our  being  able  to  learn  whether  it  trans- 
udes from  the  venous  rather  than  from  the  arterial  capillaries,  and 
vice  versa.  In  this  respect,  whether  the  discharge  be  derived  from 
the  body  or  cervix  of  the  womb,  from  the  vagina,  or  elsewhere,  the 
mechanism  of  the  funotion  is  always  the  same,  and  that  is  what  it 
imports  us  to  know. 

224.  Cessation.  The  age  at  which  the  menses  cease  to  appear 
is  not  less  variable  than  that  of  their  first  eruption.  Most  generally 
it  is  from  forty-five  to  fifty  years  ;  but  some  women  are  exempted 
at  the  age  of  forty,  or  even  at  thirty-six,  thirty,  twenty-six,  or  twen- 

M 


90  OF  MENSTRUATION. 

ty-four,  as  in  the  instances  cited  by  Haller  and  others  ;  and  of  which 
I  also  have  known  several.  Some  continue  to  menstruate  without  any 
inconvenience  until  fifty-five,  sixty,  sixty-five,  and  even  seventy  years 
of  age.  Cases  are  related  of  persons  who  have  lost  them  at  the 
usual  period,  and  become  regular  again  at  eighty,  ninety,  ninety- 
five,  or,  according  to  the  report  of  Blancardi,  even  at  one  hundred  and 
five  years  of  age.  But,  as  M.  Desormeaux  remarks,  although  these 
kinds  of  return  are  not  rare  at  sixty,  seventy,  or  seventy-five  years, 
it  is  at  least  certain  they  ought  rather  to  be  considered  as  the  sign 
of  some  disease,  than  as  a  real  resumption  of  the  menstrual  function. 
However,  in  the  fact  itself,  there  is  nothing  which  the  laws  of  the 
animal  economy  render  incomprehensible.  In  the  same  manner  as 
certain  plants  sometimes  flourish  a  second  time  in  autumn,  after 
having  been  withered  at  the  close  of  spring,  so,  also,  a  woman  may, 
under  certain  circumstances,  return,  as  it  were,  to  her  young  age 
again,  when  she  is  just  touching  the  decline  of  life.  It  is  a  last  ef- 
fort of  nature  to  restore  a  more  prosperous  season,  but  which  serves, 
unhappily,  only  to  hasten  a  dissolution  which  she  in  vain  desires  to 
retard.  Thus  it  appears  that,  in  the  natural  order,  the  menses  ought 
to  cease  between  the  fortieth  and  fiftieth  years  in  our  temperate 
climes ;  between  thirty  and  forty  in  warm  climates,  and  from  forty- 
five  to  fifty  under  the  colder  zones :  in  other  words,  their  whole 
duration  is,  every  where,  near  about  thirty  years;  where  they  are 
precocious  they  disappear  sooner,  and  where  their  appearance  is  more 
tardy  they  are  also  prolonged  to  a  later  period  of  life.  All  cases 
that  are  in  opposition  to  this  general  rule,  ought,  in  my  opinion,  to 
be  registered  as  among  the  exceptions,  or  regarded  as  pathological. 
225.  The  change  of  life  {age  du  retour)  is  mark*ed  by  the  gradual 
disappearance  of  the  charms  of  puberty;  the  bosom  and  the  cheeks 
become  flaccid,  the  skin  is  wrinkled,  appears  to  be  too  large,  and 
loses  its  delicateness  ;  the  eyes  sink  in  the  orbits  ;  the  carnation  of 
the  cheeks  is  supplanted  by  a  yellowish  tint ;  that  empurpled  blush 
which  once,  amidst  smiles,  sat  on  her  rosy  lips,  is  chased  away  by  a 
bluish'  and  leaden  hue  ;  every  circumstance  proclaims  that  the  sea- 
son of  the  pleasures  is  past,  and  that  she  can  no  longer  rely  on  the 
attractions  peculiar  to  the  sex.  It  is,  therefore,  very  prpperly,  that 
this  period  is  called  the  critical  time,  or  critical  age ;  but  attempts 
have  been  erroneously  made  to  justify  these  epithets,  by  reference 
to  the  numberless  dangers  with  which,  according  to  the  general  opi- 
nion, women  are  at  this  period  surrounded.  In  fact,  the  statistical 
researches  published  by  Moret  and  Finlayson,  MM.  Chateauneuf 
and  Luchaisc,  prove  that  not  more  women  than  men  die  between 
the  ages  of  forty  and  fifty  years.  Nevertheless,  the  menses  rarely 
cease  suddenly,  or  without  occasioning  some  disorder :  on  some  occa- 


OF  MENSTRUATION.  91 

sions  their  suppression  is  preceded  by  a  gradual  diminution  of  the 
duration  of  each  period,  and  of  the  quantity  of  blood  lost ;  or  on  the 
contrary,  by  an  increase  which  sometimes  converts  them  into  a 
pretty  abundant  hemorrhage  ;  sometimes  they  cease,  return  again  to 
cease  and  return,  before  a  final  stop  is  put  to  them  ;  they  become 
irregular  in  character  ;  a  mucous  discharge  is  established  ;  lassitude, 
sense  of  suffocation,  nervous  complaints,  even  severe  diseases  occur 
in  some  cases  ;  but  in  others,  also,  nothing  of  all  this  is  observed  to 
happen,  and  the  health,  vt'hich  up  to  that  period  had  been  precarious, 
becomes  quite  confirmed  ;  strength  is  restored  ;  the  emaciated  indi- 
vidual grows  fat,  and  finds  nothing  but  benefits  in  the  loss  of  her 
catamenial  discharges. 


ARTICLE  II. 
Of  ReprodiLction. 

226.  Designed  for  the  perpetuation  of  species,  reproduction  is  a 
function  peculiar  to  living  beings.  Inert  bodies  are  produced,  but 
never  reproduce.  Without  contradiction,  reproduction  constitutes 
one  of  the  most  astonishing  phenomena  of  animated  nature  :  and 
how  many  efforts  have  been  made,  from  the  beginning  of  time  until 
now,  to  ascertain  its  mechanism  !  Indeed,  ought  not  man,  whose 
prerogative  it  is  to  think,  first  to  endeavour  to  understand  himself? 
Can  any  thing  in  the  universe  interest  him  so  much  as  his  own  ori- 
gin ?  Yet  these  efforts  so  multiplied,  these  researches  so  ably  con- 
ducted, and  these  labours,  of  all  sorts,  pursued  so  perseveringly  by 
the  most  celebrated  men,  have  hitherto  scarcely  served  to  any 
other  end  than  to  show  him  how  deep  is,  the  mystery  that  veils  the 
commencement  of  his  existence. 

227.  Pythagoras  and  his  disciples  said  that  the  embryo  is  formed 
out  of  the  menstrual  blood,  and  a  kind  of  moisture  that  descends 
from  the  brain  during  coition,  and  that  it  is  developed  according  to 
the  laws  of  harmony. 

228.  Empedocles  and  Hippocrates,  who  are  not  less  obscure 
than  the  former  on  this  subject,  thought  that  both  the  male  and  fe- 
male enclosed  the  molecules  of  embryos  of  both  sexes,  and  that  these 
molecules  were  united  in  the  womb  during  the  sexual  union. 

229.  Aristotle,  with  certain  modifications,  reproduced  the  idea  of 
Pythagoras,  and  by  an  ingenious  metaphor,  made  of  the  womb  a  real 
sculptor's  shop,  where  the  woman  furnished  the  marble,  the  man 
brought  the  workman,  and  the  embryo  represented  the  statue. 


92  OF  REPRODUCTION. 

230.  Galen  set  forth  an  opinion  diametrically  opposite  te  that  of 
the  celebrated  naturalist  of  Stagyra  ;  he  insists  that  the  embryo  is 
produced  from  the  semen  of  the  male,  and  that  the  material  furnish- 
ed by  the  woman  serves  solely  for  its  nourishment. 

231.  R.  De  Graaf  thought  he  could  demonstrate  that  all  animals 
come  from  an  egg,  and  says  that  in  the  human  species  itself,  the 
germs  exist  in  the  ovary,  in  the  form  of  ovules,  or  little  transparent 
vesicles.  The  ancient  doctrine,  entitled  the  system  of  mixed  germs, 
was  soon  generally  abandoned,  while  the  new  hypothesis,  known  as 
the  system  of  ovules,  spread  with  the  rapidity  of  lightning.  This  is 
the  doctrine  that  prevails  at  the  present  day  ;  but  as  may  well  be 
supposed,  it  has  not  reached  the  nineteenth  century  without  having 
experienced  numerous  modifications.  According  to  De  Graaf, 
Meckel,  &c.  the  little  ovule  is  only  a  kind  of  rudimental  embryo, 
which  is  only  waiting  for  life  in  order  then  to  commence  its  own  de- 
velopment ;  and  this  life  can  only  be  imparted  to  it  by  the  prolific 
semen  of  the  male  ;  according  to  Ruysch  and  Haller,  the  seminal 
liquor  is  conveyed  unaltered,  by  the  Fallopian  tube,  to  the  ovary,  while 
others  think  that  a  very  subtle  vapour,  an  aura  seminalis,  only  is  de- 
tached from  it,  and  which  produces  the  same  eflfect ;  several  wri- 
ters have  advanced  the  opinion,  that  the  semen,  at  first  absorbed  in 
the  vagina  or  uterus,  and  carried  from  thence  into  the  torrent  of  the 
circulation,  does  not  return  to  the  ovary  to  fecundate  a  vesicle  until 
it  has  undergone  several  elaborations. 

232.  Soon  after  the  discovery  of  the  ovules,  Ham,  Harstoecker, 
and  Lewenhoeck  affirmed  th<at  the  germs  exist,  quite  formed,  in  the 
reproductive  fluid  of  the  male  ;  that  these  germs,  which  they  called 
animalcules,  are  living ;  that  a  single  drop  of  sperm  contains 
many  thousands  of  them  ;  that  bemg  projected  in  the  act  of  coition 
into  the  uterine  cavity,  they  all  perish  with  the  exception  of  one,  or 
more,  which  are  fortunate  enough  to  reach  the  Fallopian  tube  ;  that 
one  of  them  reaches  the  ovary,  enters  and  lodges  in  a  vesicle  pre- 
pared for  that  purpose,  and  afterwards  returns  to  the  womb  in  the 
shape  of  a  little  ovum,  &c.  Hence  is  established  a  new  system,  since 
called  the  system  of  animalcules,  a  system  which  gives  to  man  an 
immense  share  in  the  act  of  fecundation,  while  the  ovular  hypothe- 
sis, as  understood  by  De  Graaf,  attributes  almost  the  whole  of  it  to 
the  woman. 

233.  Harvey,  supported  by  the  munificence  of  a  great  king  ;  Hal- 
ler, with  his  extraordinary  talents  ;  Spallanzani,  with  that  good  faith 
and  spirit  of  observation  for  which  he  was  bo  remarkable  ;  for  the 
purpose  of  clearing  up  this  great  question,  multiplied  their  experi- 
ments almost  infinitely,  and  their  labours  have  led,  or  seem  to  lead, 


OF  REPRODUCTION.  93 

to  this  common  conclusion,  to  wit,  that  the  union  of  germs  takes 
place  in  the  ovary,  and  that  the  development  of  the  product  of 
fecundation  is  a  simple  evolution,  and  not  an  epigenisis,  as  was  for- 
merly maintained. 

234.  Nevertheless,  the  doctrine  of  epigenisis  has  never  been 
wholly  abandoned  ;  Maupertuis  still  defended  it  in  his  Venus  Phy- 
sique, published  in  1754,  asserting  that  the  seed  of  the  two  sexes  is 
formed  of  particles  that  are  never  commingled  save  in  the  womb, 
just  as  certain  chemical  elements  mutually  attract  and  combine  with 
each  other.  BufTon  was  even  very  near  reviving  it,  by  presenting 
it  in  a  new  light :  this  celebrated  writer  supposed  that  at  the  moment 
when  the  venereal  enjoyment  was  at  its  greatest  height,  there  were 
separated  from  every  portion  of  the  body,  and  of  the  two  conjoined 
bodies  at  the  same  moment,  a  determinate  number  of  organic  mole- 
cules ;  that  each  of  these  molecules  possessed  a  figure  proportioned 
to  the  part  of  the  body  from  whence  it  was  disengaged,  but  which 
are  similar  in  the  two  sexes ;  that  having  reached  the  uterus,  all  the 
similar  molecules  are  mutually  attracted  towards  each  other,  so  that, 
for  example,  those  that  were  furnished  by  the  eye,  the  nose,  the  ear, 
or  the  arm,  the  lung,  or  the  heart,  or  finger  of  the  woman,  can  only 
combine  with  the  molecules  from  the  eye,  nose,  ear,  arm,  lung,  heart, 
or  finger  of  the  man. 

235.  Not  one  of  these  opinions  is  wholly  destitute  of  foundation  ; 
not  one  but  has  been  defended  with  talent,  and  combated  by  very 
good  arguments  ;  none  without  its  partisans  and  antagonists  ;  but  the 
nature  of  this  work  not  admitting  of  my  entering  into  very  long  de- 
tails, so  as  to  exhibit  the  just  value  of  each  of  these  doctrines,  I  shall 
leave  the  subject  with  what  has  been  above  said. 

23G.  Reproduction,  in  those  beings  that  occupy  a  high  grade  on 
the  zoological  scale,  is  an  extremely  complex  act ;  in  order  to  a 
good  understanding  of  it  as  a  whole,  it  ought  to  be  analysed,  in  some 
measure,  in  the  several  gradations  of  the  animal  kingdom.  In  the  first 
place,  it  is  proper  to  remark,  that  the  words  reproduction,  generation, 
fecundation,  conception^  have  each  a  distinct  grammatical  accepta- 
tion, and  it  is  wrong  to  employ  them  as  synonyms,  especially  when 
speaking  of  mammiferous  animals.  The  word  reproduction,  for  ex- 
ample, is  applicable  to  the  whole  function,  while  generation  ought 
to  be  understood  as  meaning  the  simple  creation  of  germs ;  the  term 
fecundation,  in  its  turn,  only  expresses  the  act  which  unifes  the  two 
germs,  or  by  which  one  of  these  germs  vivifies  the  other  ;  the  word 
conception,  which  signifies  io  retain^  can  only  be  reasonably  employ- 
ed to  designate  the  action  which  causes  the  fecundated  germ  to  be 
retained  within  the  sexual  organs ;  lastly,  the  word  reproduction  is 


94  OF  REPRODUCTION. 

the  general  term,  while  the  three  others  belong  only  to  separate 
phenomena,  which  may  either  exist  unconjoined  or  altogether,  ac- 
cording to  the  class  in  which  they  happen  to  be  observed. 

237.  Thus  polypi,  which  reproduce  themselves  by  germs,  have 
generation,  but  no  fecundation  nor  conception.  The  batracian  rep- 
tiles also  produce  germs;  but  these  germs  are  of  two  species,  those 
of  the  male,  and  those  of  the  female  ;  they  must  be  mixed  in  order 
for  reproduction  to  take  place,  but  as  the  mixture  is  effected  ex^e- 
riorly,  the  batracians  have  no  conception,  although  they  have  both 
a  generation  and  a  fecundation.  In  birds  there  is  retention  of  the 
fecundated  germ,  and  consequently,  generation,  fecundation,  and 
conception.  In  the  manimiferaj  and  man,  the  vivified  and  conceived 
germ  is  developed  within  the  animal ;  and  there  is,  further,  in  these 
cases,  gestation,  and  even  expulsion  or  parturition,  at  the  end  of 
pregnancy.  The  function  of  reproduction  then  is  composed,  in  the 
human  species,  1 .  Of  generation,  or  the  formation  of  the  germ  ; 
2.  Oi fecundation,  or  the  vivification  of  the  germ  ;  3.  Of  conception, 
or  the  retention  of  the  vivified  germ ;  4.  Of  gestation  or  pregnancy ; 
5.  Of  parturition  or  the  expulsion  of  the  ovum. 

SECTION  1. 
Of  the  Generation  or  Procreation  of  Germs.  ^ 

238.  In  the  infusory  animals  which  break  to  pieces  of  themselves, 
and  the  zoophytes  which  we  reduce  to  fragments  that  give  birth  to 
an  equal  number  of  entire  beings,  germs  are  nothing  more  than 
analogues  of  the  general  mass  of  the  individuals  from  which  they 
have  been  separated.  Their  generation  is,  in  this  respect,  analo- 
gous to  that  of  those  plants  that  are  multiplied  by  slips  or  grafts. 
A  little  farther  on  in  the  scale,  germs  cannot  be  produced  except  by 
peculiar  organs  which  constitute  the  sexes,  and  in  that  case  the 
sexes  are  sometimes  united  in  the  same  individual,  sometimes  they 
exist  in  two  different  individuals.  Snails,  oysters,  a  pretty  consi- 
siderable  number  of  other  molusca,  and  all  the  monocccions  plants 
are  in  the  first  case,  that  is  to  say,  they  are  hermaphrodites  j  the 
tlicBcious  plants,  and  almost  all  animals  are  found  in  the  second  ;  so 
that  reproduction  is  here  bi-sexual,  and  the  male  and  female  germs 
are  always  furnished  by  different  individuals. 

§.  I.  Of  the  female  germ. 

239.  In  ascending  the  scale  from  fishes  up  to  women,  the  female 
germ  appears  to  be  formed  in  the  ovary  (233)  ;  it  is  always  found 


OF  REPRODUCTION.  95 

to  present  itself  under  the  appearance  of  a  vesicle,  known  by  the 
name  of  ovule.  In  reptiles  and  birds  the  ovule  is  very  large,  com- 
paratively to  that  of  women  ;  in  all  the  mammiferiB  its  reproduction 
is  extremely  simple  :  the  ovary  is  a  gland  whose  special  function  it 
is  to  secrete  ovules,  as  the  liver  secretes  bile,  &c.  MM.  Prevost 
and  Dumas  assure  us  that  they  have  proved  that  the  ovules  are  really 
formed  by  the  ovary,  and  by  nothing  but  the  ovary  ;  that  they  always 
exist  in  this  gland  in  adult  females,  who  are  capable  of  fecundation  ; 
that  they  are  not  developed  until  puberty,  and  are  not  found  in  old 
age  ;  that  animals  that  copulate  at  all  seasons  of  the  year  also  have 
them  without  interruption  until  they  become  sterile,  while  on  the 
other  hand  they  are  only  met  with  at  the  season  of  copulation  in 
those  animals  that  have  only  one  rutting  time  in  each  year, 

240,  These  vesicles,  at  first  very  small,  grow  at  last  to  the  size  of 
a  hempseed.  As  in  fowls,  they  do  not  all  grow  at  the  same  time  ; 
one  or  two  generally  exceeding  the  rest,  and  reaching  the  state  of 
maturity  first.  Their  coats  are  then  thick  and  opake,  rise  more  or  less 
above  the  surface  of  the  ovary,  and  seem  as  if  they  would  burst  its 
investing  membrane.  At  this  period  of  its  evolution  the  germ  is 
composed  of  two  small  coats,  one,  external,  the  largest,  adheres  to 
the  tissue  of  the  ovary  ;  the  other,  internal,  smaller,  really  constitutes 
the  ovule,  while  MM.  Prevost  and  Dumas  propose  to  restrict  the 
name  of  vesicle  to  the  former. 

24 1 ,  After  the  discovery  of  the  ovules,  and  particularly  during  the 
last  century,  philosophers  were  desirous  to  know  whether  they  are 
transmitted  from  the  mother  to  the  daughter,  together  with  the  prin- 
ciples of  her  organs ;  or  whether,  on  the  other  hand,  they  are  not 
formed  until  the  age  of  puberty.  This  question,  which  gave  rise 
to  the  celebrated  theory  of  the  encasing  of  germs  one  within  another, 
has  been  especially  argued  by  Swammerdam,  Haller  and  Bonnet. 
The  latter  insisted  with  great  zeal,  that  we  ought  to  carry  back  the 
origin  of  the  human  beings  that  now  cover,  have  covered,  or  will 
hereafter  cover  the  globe  in  all  succeeding  ages,  to  the  ovary  of  the 
first  woman ;  that  is  to. say,  that  the  ©varies  of  the  first  woman  must 
have  enclosed,  shut  up  one  within  another,  the  germs  of  all  the  ge- 
nerations that  have  succeeded,  or  will  hereafter  succeed  ;  in  a  word, 
the  whole  human  race.  But  these  infinite  divisions,  in  which  the 
imagination  loses  itself,  have  caused  the  idea  of  the  pre-existence  of 
germs  to  be  rejected,  and  at  the  present  day  they  are  regarded  as  the 
results  of  a  mere  secretion. 

§.  II.  Of  the  male  germ. 

242,  The  germ  furnished  by  male  animals  is  a  whitish,  viscid 


96  OF  REPRODUCTION. 

liquor,  called  seed^  prolific  matter^  or  seminal  fiuid ;  when  this 
liquid  escapes  from  the  urethra,  it  is  composed  of  a  substance  se- 
creted by  the  testicles,  of  the  fluid  exhaled  from  the  vesiculas  semi- 
nales,  and  of  the  prostatic  liquor.  But  which  of  all  these  various 
elements  is  the  fecundating  principle  ?  It  is  not  the  aura  seminalis; 
for  Spallanzani  could  never  fecundate  the  eggs  of  frogs  without 
bringing  them  into  immediate  contact  with  the  seminal  liquor  of  the 
male.  Does  it  result  from  the  mixture  that  I  have  just  mentioned  ? 
No  ;  for  the  fluids  furnished  by  the  vesicular  seminales,  the  prostate 
and  the  urethra,  can  only  be  regarded  as  the  vehicle  of  that  derived 
from  the  testicles.  Does  it  depend  upon  the  animalcules  named  after 
Lewenhoeck  ?  Several  authors  maintain  the  affirmative,  and  their 
opinion  has  found  numerous  echoes  in  various  parts  of  the  learned 
world. 

243.  According  to  Lewenhoeck,  the  animalcules  are  microscopic 
corpuscles,  endowed  with  the  faculty  of  moving  in  a  determinate  di- 
rection, and  for  a  determinate  end.  Their  large  extremity,  which 
is  also  flattened,  gives  origin  to  their  caudiform  portion,  which  is 
delicate  and  very  much  elongated.  According  to  some  of  his  parti- 
sans, they  may  be  divided  into  young,  old,  adult,  weakly,  strong, 
male  and  female,  &.C.;  and  Plantade,  of  Montpellier,  under  the 
assumed  name  o^Dalempatius,  refining  still  more  on  what  had  been 
already  advanced  upon  this  subject,  made  out  of  a  drop  of  prolific 
liquor  a  well  governed  nation  ;  he  imagined  a  king,  princes,  minis- 
ters, magistrates,  paupers,  rich  persons,  merchants,  soldiers,  chil- 
dren, old  men,  &c.  Raillery  produced  on  this  occasion  an  effect 
that  could  not  be  brought  about  by  the  most  peremptory  reasoning. 
The  animalcular  hypothesis  appeared  to  be  absurd,  and  thenceforth 
nobody  dared  to  advocate  it. 

244.  It  is  true  that  it  had  already  been  asserted  that  these  corpus- 
cles exist,  and  that  they  sometimes  exhibit  the  form  that  had  been 
assigned  to  them,  but  that  they  also  appear  on  some  occasions  un- 
der another  form,  and  that  they  do  not  in  any  case  belong  more 
peculiarly  to  the  seininal  liquor  than  to  aqy  other  of  the  animal 
fluids;  in  a  word,  that  they  do  not  play  any  special  part  in  the  act 
of  reproduction,  or  at  the  least,  they  are  not  the  essential  agents  of 
fecundation. 

246.  According  to  MM.  Prevost  and  Dumas,  the  animalcules  de- 
scribed by  Lewenhoeck  do  not  exist  except  in  the  male  organs  of 
generation,  and  difler  from  the  mobile  globules  of  the  other  fluids  of 
the  organi.siii  by  their  form,  which  is  always  the  same  in  the  same 
zoological  1  y  their  mode  of  progression  ;  by  the  situation  in 

which  they  ...^  ......id,  &c.;  they  always  have  an  enlarged  extremity 


OF  REPRODUCTION.  97 

and  an  elongated  portion  ;  their  head,  which  is  sometimes  oval  or 
almost  circular,  sometimes  lozenge-shaped,  at  others  resembles  the 
catkin  of  the  bul-rush  ;  but  as  it  is  at  the  same  time  flattened,  it 
cannot  be  recognized,  except  when  seen  in  front.  Their  point, 
sometimes  straight,  very  long,  and  conical  as  in  the  dunghill  cock, 
sometimes  short  and  fine  as  in  the  dog,  at  others  very  long  and  flex- 
ous,  pretty  much  resembles  the  tricocephalous  worms,  or  the  slen- 
derest worms  that  inhabit  the  human  body.  Upon  the  whole,  the 
spermatic  animalcula  has  a  general  resemblance  to  the  tadpole  of 
the  batracians  ;  its  dimensions  do  not  exceed  one,  two,  or  three 
hundredths  of  a  millimeter  ;  it  is  net  to  be  seen  in  the  seminal  liquor 
previous  to  the  age  of  puberty,  nor  in  old  men,  nor  in  the  interval 
of  the  seasons  at  which  certain  animals  copulate,  nor  in  the  mule, 
which,  as  is  well  known,  is  incapable  of  reproduction  ;  it  is  not  met 
with  in  the  matter  furnished  by  the  urethra,  the  prostate,  or  the  se- 
minal vesicles,  and  it  is  to  be  found  with  the  same  characters  in  all 
those  animals  that  are  wholly  or  partially  deprived  of  these  organs. 
It  is  produced  by  the  testicle  which  secretes  it.  Every  prolific  animal 
contains  it  in  its  prolific  gland,  and  frequently  in  its  deferent  duct.  The 
movement  of  these  corpuscles  seems  to  take  place  under  the  influence 
of  a  will;  they  always  move  forwards  ;  they  can  be  killed  by  an  elec- 
tric discharge,  and  thenceforth  their  motion  ceases  to  be  active.  In 
escaping  from  the  formative  gland,  the  viscous  matter  in  which  they 
are  enveloped  is  too  thick  to  permit  them  to  exercise  any  visible 
motion  ;  but  it  is  only  necessary  to  mix  them  with  some  other  liquid, 
or  permit  them  to  become  diluted  in  the  seminal  vesicle  or  urethra, 
in  order  that  their  mobility  should  come  immediately  into  play. 

246.  Simple  microscopic  globules,  on  the  contrary,  have  neither 
head  nor  tail,  are  round  or  of  irregular  shapes,  sometimes  larger 
and  sometimes  smaller,  and  move  only  under  the  influence  of  some 
external  impression,  and  without  any  determinate  end.  They  exist 
in  all  the  fluids  of  the  economy,  in  the  blood,  in  the  serum,  in  the 
milk,  even  in  the  spermatic  liquor,  before  puberty,  as  well  as  at  all 
other  periods  of  life,  and  in  all  animals. 

247.  MM.  Prevostand  Dumas  by  their  numerous  experiments  on 
artificial  fecundation,  became  convinced  that  the  animalcules  alone 
constituted  the  germ ;  they  never  effected  a  vivification  when  the 
liquid  they  made  use  of  did  not  contain  them,  or  when  these  living 
molecules  had  been  killed  or  destroyed  in  any  way,  whereas  fecunda- 
tion took  place  whenever  the  liquor  they  employed  contained  even 
a  few  animalcules. 

248.  Although  the  experiments  of  these  physiologists  bear  marks 
of  the  greatest  good  faith  and  accuracy,  I  cannot,  nevertheless, 

N 


98  OF  REPRODUCTION. 

witbhold  all  reference  to  the  authorities  which  prevent  us  from 
adopting,  excepting  in  the  most  circumspect  manner,  the  conclusions 
that  might  be  drawn  from  them.  In  Italy,  Spallanzani  has  main- 
tained that  animalcules  are  completely  foreign  to  the  fecundative  act ; 
in  spite  of  the  assertions  of  Gleichen,  the  opinion  of  Spallanzani 
prevails  in  Germany  ;  in  France,  MM.  Bory  de  Saint  Vincent 
and  Dutrochet  are  of  nearly  the  same  opinion;  M.  Virey  regards  them 
as  containing  certain  small  balloons  distended  with  a  kind  of  pollen, 
and  which  burst  when  they  reach  the  organs  of  the  other  sex  ;  and 
M.  Raspail  has  very  recently  come  out  against  the  doctrine  of  ani- 
malcules, which,  according  to  him,  are  nothing  more  than  certam 
organic  debris,  or  products  of  the  decomposition  of  the  ^erm. 

249.  What,  among  so  many  contradictory  assertions,  are  we  to 
believe  ?  what  opinion  must  we  adopt  ?  However  it  may  be,  we 
may  consider  it  as  demonstrated  that  the  female  germ  is  an  ovule, 
and  that  that  of  the  male  is  contained  in  his  spermatic  fluid,  and 
that  this  liquid  contains  such  animalcules  as  were  described  by  Lew- 
enhoeck  ;  but  that,  in  the  present  state  of  science,  the  relative  im- 
portance of  each  of  these  principles  is  unknown. 


SECTION  2. 
Of  Fecundation. 

260.  When  the  germs  have  acquired  their  full  size,  a  new  pheno- 
menon, by  combining  some  of  their  principles,  imparts  to  them  mo- 
tion and  life  ;  this  phenomenon  is  fecundation,  which,  as  to  its  inti- 
mate mechanism,  is  perhaps  always  effected  in  the  same  manner,  but 
which  appears  to  be  effected  in  different  ways  in  different  animated 
beings.  Although  the  snail  has  double  sex,  it  cannot  fecundate  itself; 
a  copulation  with  another  individual  similar  to  itself  is  necessary,  and 
then  each  of  them  fecundates,  and  is  at  the  same  time  fecundated. 

261.  Just  as  it  happens  in  the  monocccious  plants,  where,  so  to 
speak,  the  pollen  meets,  by  accident  only,  the  ovary  of  the  female 
individual;  so  in  many  fishes  and  molusca,  chance  only  seems  to  lead 
the  male  to  where  the  female  had  deposited  her  ova,  so  that  he  may 
bedew  it  with  his  sperm. 

252.  In  the  batracian  animals,  such  as  the  frog,  although  there  is 
no  real  copulation,  copulation  is,  nevertheless,  requisite,  and  fecun- 
dation is  effected  while  the  female  ova  are  in  the  act  of  escaping  from 
her  organs. 

263.  Lastly,  in  the  ophidian  animals,  birds,  the  mammifera;,  and 
man,  it  is  necessary  that  the  germ  of  the  male  should  fecundate  the 
other  in  the  interior  of  the  female  organs. 


OF  REPRODUCTION.  99 

254.  Seat.  But  the  point  in  the  organs  at  which  the  two  germs 
meet  is  not  yet  completely  ascertained.  Is  it  in  the  ovary  ?  Is  it 
in  the  oviduct  ?  Is  it  in  the  womb  ?  All  the  ancients  agreed  that 
the  vivification  of  the  germs  takes  place  in  the  womb,  whether,  like 
Pythagoras,  they  call  to  their  aid  an  extremely  subtle  nervous  prin- 
ciple, whether  they  invoke,  like  Harvey,  a  magnetic  impr^nation,  or 
whether  they  content  themselves  with  the  seminal  liquor  of  the  male, 
to  explain  the  fact :  almost  all  the  ovarists,  on  the  contrary,  have 
thought  it  could  only  be  effected  in  the  ovary,  and  a  great  majority 
of  the  physiologists  of  the  present  day  are  of  this  way  of  thinking. 

255.  Among  the  animalculists,  one  party  believed  that  fecundation 
takes  place  in  the  womb  without  any  participation  by  the  ovule,  or 
with  Maupertuis,  that  the  animalcules  attracted  the  ovarian  vesicles 
to  the  womb  in  order  to  effect  their  agglomeration  or  germifica- 
tion.  Others,  with  Andry,  supposed  that  a  single  animalcule  reaches 
the  ovary,  enters  an  ovule  by  lifting  a  small  valve,  and  that  fecunda- 
tion is  effected  at  that  moment.  Finally,  MM.  Prevost  and  Dumas, 
returning  in"  this  respect  to  the  idea  of  Buffon,  of  Maupertuis,  of 
Aristotle  and  Hippocrates,  admit  that  the  uterine  cavity  is  the  seat 
of  fecundation. 

256.  To  maintain  this  last  hypothesis,  they  rely  on  the  circum- 
stance that  they  were  never,  in  their  experiments,  able  to  find  any 
animalcules  in  the  Fallopian  tubes,  and,  a  fortiori^  in  the  ovaries  ; 
while  they  frequently  met  with  them  in  the  womb  or  its  horns ;  on  the 
fact,  that  before  the  ovules  can  become  impregnated^  they  must  be 
enveloped  in  a  coat  of  mucus,  which  they  receive  while  in  the  tube  on 
their  way  to  the  womb ;  that  they  could  never  succeed  in  the  artificial 
fecundation  of  ovules  taken  directly  from  the  ovary,  while  nothing  was 
easier  than  to  vivify  such  as  had  traversed  the  tube  and  the  oviduct, 
&c.  But  Ruysch  saw  the  prolific  matter  in  the  Fallopian  tubes  of  a 
woman  who  was  taken  in  adultery  and  killed  on  the  spot  by  her  hus- 
band; Haller  found  semen  in  the  seminiferous  ducts  of  the  female  ani- 
mals on  which  he  experimented.  Besides,  are  we  authorised  to  deny 
the  existence  of  a  fact  observed  by  others,  because  we  have  ourselves 
sought  for  it  in  vain  ?  Have  we  a  right  to  infer,  because  the  eggs 
of  frogs  cannot  be  fecundated  unless  they  have  been  previously  more 
or  less  thickly  covered  with  a  coating  of  mucus,  that  the  same  thing 
holds  true  in  women  ?     Further,  these  ovules  which  MM.  Prevost 

'  and  Dumas  found  unfit  for  fecundation,  could  not  have  been  forcibly 
detached  from  the  ovary  without  having  been  somewhat  altered  by 
the  instrument ;  and  that  too,  by  the  admission  of  the  experimenters 
themselves.  Though  the  existence  of  ovarian  pregnancies  is  far 
from  being  demonstrated ;  though  the  fact  of  an  embryo  half  in  the 


100  OF  REPRODUCTION. 

tube  and  half  in  the  ovary,  as  reported  by  Bussiere,  requires  some 
new  evidence ;  though  a  great  many  cases  of  extra-uterine  preg- 
nancy, examined  with  care,  are  very  far  from  being  conclusive,  the 
experiments  of  Nuck,  who  placed  a  ligature  on  the  tube,  betwixt  the 
womb  and  ovary,  directly  after  copulation,  and  upon  killing  the 
animal  some  time  afterwards,  found  that  fecundation  had  taken  place, 
and  that  the  ovum,  stopped  by  the  thread,  had  begun  to  develope 
itself  in  the  ovarian  moiety  of  the  seminiferous  canal ;  those  of 
Haighton,  who  found  that  fecundation  did  not  take  place  in.  rabbits 
on  that  side  where  he  had  tied  the  tube,  &c.,  appear  to  prove  in- 
contestably,  that  the  union  of  the  germs  does  not  take  place  in  the 
womb. 

257.  Mechanism.  As  to  the  mechanism  of  this  union,  it  is  still 
covered  with  an  extremely  thick  veil.  After  coition,  one  of  the 
vesicles  enclosed  in  the  ovary  enlarges  with  great  rapidity,  soon  rises 
above  the  surface  of  the  organ,  gradually  thins  its  coat,  which  at 
length  bursts;  when  this  vesicle  bursts,  a  much  smaller  vesicle, 
which  is  the  real  germ,  escapes  from  it  (239);  this  germ  engages  at 
once  in  the  tube,  which  meanwhile  was  spasmodically  applied,  like 
a  cupping-glass,  to  the  portion  of  the  ovary  from  which,  during  a 
fruitful  coition,  the  vesicle  escapes. 

268.  The  capsule  which  contained  the  germ  before  it  was  rup- 
tured, constitutes  what  has  by  Valisnieri,  Santorini,  Cruikshank, 
Bufibn  and  Home,  been  called  the  yellow  body  {corpus  luteum);  its 
rupture  occasions  a  small  bleeding  wound,  which  cicatrizes  by  de- 
grees, and  leaves  in  its  place  a  wrinkle  or  depressed  scar,  more  or 
less  deep,  and  which  Littre,  Haller,  and  some  others  mistook  for  the 
real  yellow  body. 

259.  That  which  takes  place  in  regard  to  a  single  ovule,  may 
also  occur  to  two,  to  three,  or  a  greater  number.  Supposing  that 
the  evolution  of  the  ovule  is  put  in  play  by  the  commotion  that  ac- 
companies coition,  by  a  sort  of  electric  commotion,  by  an  aura 
seminalis,  by  means  of  an  animalcule,  or  by  any  principle  whatsoever 
of  the  prolific  matter  ;  that  this  principle  reaches  the  germ  directly 
from  the  woman,  or  that  it  reaches  it  only  after  having  passed  through 
the  general  circulation,  it  always  happens  that  after  a  fecundation 
has  been  effected,  there  is  detached  from  the  ovary  an  ovule  so  modi- 
fied, that  it  is  soon  recognized  as  a  being  similar  to  the  one  that 
produced  it.  This  is  what  is  demonstrated  by  observation  ;  but  we 
know  nothing  further  about  it.  The  systems  of  preformation  or 
evolution^  o[ emboitcment  or  panspermy,  oicpigenesis  and  catagenesis^ 
expansive  forccy  resisting  force  of  the  ancients  ;  the  nistisformativus 
of  Blumenbach,  reproduced  under  a  new  point  of  view,  and  clothed 


OF  REPRODUCTION.  101 

by  M.  Mayer  with  the  philosophical  jargon  of  the  German  schools, 
teach  us  nothing  in  relation  to  the  intimate  nature  of  this  work,  which 
is  as  extraordinary  as  it  is  curious. 


SECTION  3. 

Of  Conception. 

260.  When  the  union  of  the  germs  is  effected  in  the  interior,  the 
new  product  resulting  therefrom  is  commonly  retained,  or  arrested  in 
some  part  of  the  sexual  system.  But  this  phenomenon  constitutes 
what  is  properly  called  conception.  It  is  evidently  distinct  from 
fecundation ;  for  wherever  the  latter  is  effected  exteriorly  to  the 
.animal,  as  in  fishes  and  many  reptiles,  conception  cannot  be  truly 
said  to  exist,  while  in  the  higher  classes  it  always  does  exist.  At  a 
first  view,  it  might  seem  useless  to  make  a  distinct  phenomenon  of 
it,  and  that  it  might  without  inconvenience  be  confounded  with  ges- 
tation ;  but  upon  a  closer  inspection,  we  are  easily  convinced  of  the 
contrary.  Indeed,  the  ophidians  and  birds  have  no  gestation,  and 
yet  they  have  a  conception.  Conception,  therefore,  comprehends 
what  takes  place  between  the  instant  of  vivification  and  the  moment 
when  the  fecundated  germ  begins  to  be  developed ;  whether  it  at- 
taches itself  for  this  purpose  to  some  point  of  the  generative  pas- 
sages, or  whether  it  has  to  be  expelled  in  order  to  undergo  the  pro- 
cess of  incubation  exteriorly. 


102 


CHAPTER  HI. 

History  of  Gestation. 

261.  If  the  fecundated  or  conceived  ovum  passes  out  of  the  organs 
of  the  mother  before  the  germ  begins  its  development,  as  in  birds, . 
there  is  no  gestation,  and  the  animal  is  called  oviparous.  If  the 
embryo  is  formed  while  passing  through  the  oviduct,  but  so  that  it 
cannot  separate  itself  from  its  shell  until  after  it  is  laid,  as  in  certain 
reptiles,  there  is  still,  properly  speaking,  no  gestation,  and  such  ani- 
mals are  called  ovo -viviparous.  Whenever,  on  the  contrary,  the  egg 
undergoes  its  entire  incubation  in  the  interior  of  the  generative  sys- 
tem, and  the  foetus  is  not  expelled  until  the  development  of  its  organs 
enables  it  to  live  and  grow  in  the  external  world,  pregnancy  or  ges- 
tation is  said  to  exist ;  this  is  observed  to  take  place  in  the  mammi- 
ferae  only  ;  in  this  case  there  exists  a  gestative  organ,  a  single  uterus, 
or  one  womb  and  two  qd  uterum^  destined  to  lodge  the  product  of 
fecundation  until  it  attains  its  maturity,  and  such  animals  are  deno- 
minated viviparous. 

Pregnancy,  in  the  human  species,  is  one  of  the  phenomena  of  re- 
production which  it  most  imports  us  carefully  to  study.  The  words 
pregnancy  and  gestation  are  not  synonymous  with  the  words  preg- 
nant woman,  or  woman  with  child.  The  former  express  a  function, 
and  all  that  appertains  thereto,  from  its  origin  until  its  termination. 
The  latter  indicate  merely  the  actual  state  of  a  woman  who  contains 
within  herself  a  fecundated  or  conceived  ovum. 

262.  Division.  If  the  fecundated  ovum  reaches,  without  being  ob- 
structed, the  cavity  of  the  womb,  and  maintains  itself  there,  the  preg- 
nancy is  said  to  be  good,  natural,  or  uterine;  if  it  remains  and  is  devel- 
oped in  the  ovary,  if  it  falls  into  the  cavity  of  the  peritoneum,  stops  in 
the  Fallopian  tube,  or  becomes  engaged  in  the  substance  of  the  womb 
itself,  it  on  the  contrary  receives  the  title  of  bad,  preternatural,  or 
extra-uterine.     The  first  species  is  then  divided  into  three  varieties. 

1.  Simple  pregnancy,  where  the  womb  contains  only  a  single  ovum. 

2,  Double,  triple,  quadruple,  or  compound  pregnancy,  when  there 


HISTORY  OF  GESTATION.  103 

are  two,  three,  or  four  foetuses.  3.  Complicated  pregnancy,  where 
a  polypus,  a  great  quantity  of  water,  or  any  diseased  state  of  the 
product  of  the  conception,  or  of  the  womb  itself  takes  place. 

The  second  comprises  four  varieties  determined  by  the  seat  oc- 
cupied by  the  fecundated  germ  ;  so  that  authors  admit,  1 .  An  ova- 
rian pregnancy ;  2.  An  abdominal  or  peritoneal  pregnancy ;  3.  A 
tubal  pregnancy ;  and  4.  A  mixed  or  interstitial  pregnancy. 

After  having  observed  that  a  great  variety  of  diseases,  sometimes 
give  rise  to  most  of  the  symptoms  of  pregnancy,  the  French  writers, 
adopting  a  still  more  general  first  division,  have  established  a  true 
and  di.  false  or  apparent  pregnancy^  difliering  from  each  other  in  this, 
that  the  former  is  characterized  by  the  presence,  and  the  latter  by 
the  absence  of  the  fcetus  ;  they  have  next  described  false  pregnancy 
as  ventose,  serous,  sanguine,  polypous,  cancerous,  nervous,  molar, 
•hydatic,  &c.,  accordingly  as  the  increased  size  of  the  belly  depends 
on  the  presence  of  gas,  water,  blood,  polypous  or  other  tumours  in 
the  womb,  the  existence  of  a  scirrhus,  an  hydatiform  or  fleshy  mole, 
an  undelinable  nervous  state,  &c. 


ARTICLE  I. 
Of  True  Pregnancy. 

SECTION  1. 
Of  Uterine  Pregnancy. 

263.  As  soon  as  pregnancy  takes  place,  important  and  numerous 
phenomena  are  manifested  in  the  economy.  Of  these  some  are 
local,  physical,  material :  others  are  variable,  transient,  general : 
some  are  common  to  all  kinds  of  gestation,  while  others  are  peculiar 
to  some  sorts  only. 

As  uterine  pregnancy  comprises  almost  all  of  them,  and  further, 
as  it  constitutes  the  only  normal  kind  of  gestation  in  the  human 
species,  I  shall  speak,  in  the  first  place,  only  of  those  which  belong 
to  it,  and  shall  not  treat  of  the  special  phenomena  until  I  come  to 
the  article  in  which  I  shall  designate  the  means  of  distinguishing  it 
from  all  the  rest. 

264.  The  constitutional  movement  occasioned  by  copulation  is 
only  momentary,  both  in  women  and  in  men,  where  fecundation  is 


104  OF  TRUE  PREGNANCY. 

not  to  result  from  it.  In  the  opposite  case,  the  state  of  turgcscence, 
of  erection  or  spasm  of  the  uterus  and  tubes,  continues,  and  is  the 
prelude  to  a  new  kind  of  life  in  the  former  of  these  organs.  Its 
volume,  its  form,  its  situation,  attitude,  structure,  its  properties,  all 
are  about  to  be  changed. 

265.  Volume.  After  a  conception  takes  place,  the  womb  re- 
mains in  a  state  of  fluxion,  which  gradually  augments  its  size  in 
every  direction  :  according  to  some  accoucheurs,  this  growth  is  very 
regular  and  uniform  until  the  end  of  the  pregnancy  ;  others  assert 
that  it  is  irregular  and  by  starts.  M.  Desormeaux  thinks  it  is  per- 
fornt>ed  very  slowly  in  the  first  months,  and  on  the  contrary,  with 
great  rapidity  in  the  two  or  three  last ;  in  the  first  case,  at  the  ex- 
pense of  the  walls  of  the  organ  alone,  and  in  the  last,  of  the  walls 
and  cavity  both.  Not  only  does  the  body  undergo  this  augmenta- 
tion ;  Madame  Boivin  maintains,  that  in  the  second  month,  the  neck 
is  almost  two  inches  in  length.  At  the  end  of  the  third  month,  the 
womb  is  nearly  two  inches  and  a  half  through  in  every  direction, 
and  three  inches  and  a  half  in  the  fourth  month.  At  this  last  nam- 
ed period,  we  observe  in  the  dead  subject,  that  the  plaits  near  the 
inner  orifice  are  unfolded,  and  extended  in  long,  very  delicate 
ridges. 

266.  At  seven  months,  the  superior  third  of  the  cervix  has  be- 
come common  with  the  inferior  portion  of  the  body,  from  which  it 
may  however  be  distinguished  by  a  rose-coloured  zone,  very  differ- 
ent from  the  deep  red  tint  of  the  rest  of  the  womb.  Its  inferior 
portion,  whiter,  larger,  and  softer  than  the  other,  has  still  a  dimen- 
sion of  about  fifteen  lines  ;  but  we  must  not  here  confound  the  neck, 
properly  so  called,  with  the  os  tineas,  which  is  only  five  or  six  lines 
long.  The  neck,  which  is  thicker  below  than  above,  is  still  about 
an  inch  long  at  eight  months,  and  is  not  wholly  lost  in  the  uterine 
ovoid,  until  in  the  course  of  the  ninth  month  ;  so  that,  from  the 
commencement  of  pregnancy  until  the  eighth  month,  it  grows  thin- 
ner, deploys,  and  is  gradually  widened,  without  losing  meanwhile 
much  of  its  real  length. 

267.  While  admitting  a  part  of  these  assertions  to  be  true,  I 
think  it  nevertheless  more  correct  to  say  with  M.  Desormeaux,  that 
if  we  leave  the  os  tinea)  out  of  the  question,  the  neck  loses  about 
one-third  of  its  total  length  by  the  fifth  month,  one-half  in  the  sixth, 
two-thirda  or  three-fourths  in  the  seventh,  three-fourths  or  four- 
fifths  in  the  eighth,  and  the  remainder  disappears  in  the  course  of  the 
ninth. 

2G8.  At  full  terra  the  vertical  diameter  of  the  womb  is  twelve 
inches  in  length,  the  antcro-posterior  nine  inches,  and  the  trans- 


OF  TRUE  PREGNANCY.  105 

verse  eight  and  a  half.  At  the  level  of  the  tubes,  its  circumference 
is  about  twenty-six  inches,  and  only  thirteen  at  the  uterine  portion 
of  the  cervix,  which,  according  to  Madame  Boivin,  ought  then  to  be 
five  inches  higher  than  the  external  orifice.  Levret  says  that  the 
superficies  of  the  womb,  which,  when  unimprcgnated,  is  only  equal 
to  sixteen  inches,  is  three  hundred  and  thirty-nine  at  the  commence- 
ment of  labour;  that  its  cavity,  which  is  four-fifths  of  an  inch  in  the 
former  case,  rises  to  four  hundred  and  eight  in  the  latter  ;  that  its 
mass,  which  is  only  four  inches  and  a  third  before  pregnancy  begins, 
is  fifl;y-one  at  child-birth  ;  but  the  cavity  of  the  womb  is  evidently 
carried  too  far  by  Levret,  for  in  this  way  it  might  hold  seventeen 
pounds  of  water,  while  the  whole  ovum  in  general  does  not  weigh 
more  than  from  seven  to  ten  pounds. 

269.  Form.  Instead  of  remaining  flattened  on  its  two  surfaces, 
the  womb  becomes  rounded,  and  soon  grows  of  a  pyriform  shape. 
The  vaginal  angle  seems  to  contract ;  to  grow  smaller ;  its  orifice 
sometimes  becomes  circular,  or  ceases  to  represent  a  simple  linear 
or  transverse  slit,  particularly  in  first  pregnancies  ;  on  other  occa- 
sions it  is  pretty  largely  open,  its  lips  become  thicker  and  softer, 
chiefly  in  those  women  who  have  borne  several  children.  In  some 
instances  of  first  pregnancy,  it  seems  to  close  completely  up,  so  that 
it  can  scarcely  be  distinguished  by  the  finger. 

270.  The  womb  next  gradually  assumes  the  form  of  an  oval,  with 
its  point  downwards.  Its  posterior  wall,  which  was,  even  before 
impregnation  (153),  more  protuberant  than  its  anterior  one,  grows 
80  disproportionately  that  the  tubes  seem  to  descend  ponsiderably, 
until  their  roots  appear  to  answer  to  the  point  of  union  of  the  pos- 
terior two-thirds,  and  anterior  third  of  the  uterine  circumference. 
Its  fundus  also  enlarges  very  much.  Of  dimensions  nearly  equal  in 
every  direction,  about  the  fifth  or  sixth  month  the  organ  of  gestation 
exhibits  the  figure  of  a  spheroidal  vase  terminated  by  a  very  short 
neck ;  it  might  be  compared  to  a  hog's  bladder,  with  the  urethral 
extremity  served  round  with  thread  for  the  space  of  an  inch  or  two : 
supposing  that  some  one  should  now  unwind  the  thread  by  degrees, 
from  above  downwards,  while  another  blows  into  the  bladder  from 
the  fundus,  so  as  to  distend  it,  we  can  acquire  a  pretty  clear  idea  of 
the  gradual  efiacement  of  the  apex  of  the  womb. 

271.  At  the  close  of  pregnancy,  the  neck  is  nothing  more  than  a 
ring,  formed  merely  by  the  lips  of  the  os  tincse,  and  the  thickness  of 
which  varies  according  as  the  woman  is  in  her  first  pregnancy,  or 
as  she  has  already  had  several  children.  In  the  former  case,  this 
ring  scarcely  exists ;  a  circle  that  grows  thinner  and  thinner,  and 
sometimes  quite  sharp  at  its  edge,  is  ordinarily  substituted  for  it ; 

O 


106  OF  TRUE  PREGNANCY. 

in  the  second,  it  pretty  often  retains  a  thickness  of  two,  three,  or 
lour  lines,  until  labour  comes  on.  Its  orifice  remains  habitually 
closed ;  its  lips  are  smooth,  even  and  thin,  even  to  the  last,  in  those 
who  have  never  borne  children ;  in  others  it  gapes  a  little  at  an  early 
period ;  I  have  in  many  cases  been  able  to  introduce  the  end  of  my 
finger  into  it,  in  women  who  were  five  and  a  half  or  six  months 
gone,  and  who  were  used  for  the  purposes  of  the  practical  lessons 
of  my  lying-in-room.  Wider  and  softer  below,  it  is  then  found  to 
be  harder  and  narrower  above ;  its  cavity  resembles  a  pretty  long 
finger  of  a  glove,  so  that  we  can  touch  the  naked  membranes,  and 
ascertain  the  position  of  the  child  several  nionths  before  the  end  of 
pregnancy. 

272.  Position.  At  the  same  time  that  the  length  and  volume  of 
the  womb  are  increasing,  it  undergoes  other  changes,  both  of  its 
posture  and  relations  to  other  parts ;  the  cervix  is  depressed,  and 
approaches  nearer  to  the  vulva  :  this  phenomenon,  which  is  very  de- 
cided in  some  women,  and  scarcely  appreciable  in  others,  ismost  fre- 
quently met  with,  and  is  observable  for  a  longer  time  in  women  who 
have  the  pelvis  large,  and  who  are  of  a  soft  or  naturally  lax  fibre ;  and 
less  commonly  in  those  of  an  opposite  constitution,  although  it  is  not 
a  rare  thing  to  find  it  in  young  and  robust  women,  even  in  a  first 
pregnancy ;  but  the  os  tineas  does  not  fail  to  rise  up  by  degrees ;  at 
three  months,  it  is  about  at  the  same  place  it  occupied  before  im- 
pregnation ;  after  this,  continuing  gradually  to  rise,  it  sometimes 
gets  as  high  as  the  sacro- vertebral  angle,  while,  on  the  contrary,  it 
begins  in  other  instances  to  descend  again,  at  about  the  sixth,  the 
seventh  or  eighth  month,  and  approaches  pretty  near  the  inferior 
strait. 

273.  The  fundus^  which  at  the  third  month  is  not  higher  than 
the  level  of  the  superior  strait,  rises  two  finger  breadths  above  it  in 
the  course  of  the  fourth,  approaches  to  the  navel  in  the  fifth,  gets  on 
a  level  with  that  central  point,  or  even  above  it,  at  the  end  of  tlie 
sixth,  still  goes  upwards  in  the  seventh  and  eighth,  but  never  reaches 
either  the  diaphragm  or  liver,  nor  does  it  ever  fill  up  the  epigastric 
region,  as  has  been  hyperbolically  or  thoughtlessly  stated  by  some 
of  the  standard  authors.  I  have  observed  that  it  often  remains  in 
the  meso-gastric  region  until  labour  takes  place.  Besides,  with 
some  exceptions,  it  can  scarcely  iiappcn  otherwise,  for  in  the  last 
months  of  pregnancy,  the  centre  of  the  pelvis  is  often  from  fifteen  to 
eighteen  inches  distant  from  tlic  navel.  However,  the  womb,  being 
burlhcncd  as  it  were  with  the  weight  of  the  ovum,  seems  to  sink  or 
to  be  somewhat  crushed  downwards ;  wliicJi  compels  it  to  enlarge 


OF  TRUE  PREGNANCY.  107 

proportionably  in  the  transverse  and  in  the  antero-posterior  diame- 
ters, which  until  then  it  \}nd  not  done. 

274.  Direction.  While  the  womb  remains  unconstrained  in  the 
excavation,  and  its  fundus  is  not  arrested  by  (he  base  of  the.  sacrum, 
its  posterior  half,  forming  a  larger  mass  than  its  anterior  half,  tends 
to  make  it  turn  over  backwards,  so  that  as  the  os  tincjE  sinks  down- 
wards, it  inclines  forwards,  sometimes  more,  sometimes  less,  and 
gets  farther  from  the  sacrum,  and  nearer  to  the  pubis  ;  a  deviation 
that  is  favoured  by  the  alternate  fulness  and  emptiness  of  the  urinary 
bladder.  Imperfectly  supported  in  front  by  the  abdominal  parietes, 
pressed  upon  through  the  medium  of  the  viscera  by  the  diaphragm, 
and  particularly  as  the  woman  in  order  to  maintain  her  equilibrium 
is  obliged  to  carry  her  head  and  shoulders  somewhat  backwards,  the 
womb,  as  soon  as  it  is  sufficiently  enlarged  to  touch  the  promontory, 
can  no  longer  rise  except  in  the  line  of  the  axis  of  the  superior  strait. 
Applied  posteriorly  against  a  solid,  salient  and  rounded  part,  it  with 
difficulty  preserves  its  station  on  the  median  line,  as  it  proceeds  up- 
wards into  the  abdomen,  almost  always  deviates  to  one  side  or  the 
Other,  to  the  right  eight  times  out  of  ten,  so  that  one  of  its  sides,  the 
left  if  the  inclination  is  to  the  right,  and  the  right  if  it  is  inclined  to 
the  left,  soon  turns  forwards  ;  whence  it  happens,  that  its  anterior 
region  looks  a  little  to  the  right  in  the  former  instance,  and  to  the 
left  in  the  latter ;  in  a  word,  the  womb  seems  to  have  turned  on  its 
great  axis. 

275.  The  inclination  of  the  womb  to  the  right  rather  than  to  the 
left,  has  been  explained  in  a  hundred  different  ways.  The  presence 
of  the  rectum,  habitually  filled,  in  pregnant  women,  with  hard  ster- 
coraceous  matter,  has  appeared  to  some  persons  sufficient  to  account 
for  it ;  but  the  right  lateral  obliquity  is  to  be  met  with  also  in  per- 
sons who  are  not  of  a  costive  habit,  and  even  in  individuals  labouring 
under  diarrhoea.  M.  Desormeaux  adds,  that  while  rising  into  the 
abdomen,  the  organ  of  gestation  is  thrust  to  the  right  by  the  mass  of 
small  intestines,  and  the  sigmoid  flexure  of  the  colon  ;  which  de- 
pends, says  he,  on  this,  that  the  mesentery,  fixed  on  the  front  of  the 
spine,  descends  obliquely  from  right  to  left.  But  there  is  an  error 
as  to  the  fact  here,  for  the  mesentery  is  directed  from  left  to  right ; 
and  I  am  astonished  that  M.  Desormeaux,  in  general  so  correct, 
should  have  overlooksd  it ;  besides,  though  the  sigmoid  flexure  of 
the  colon  is  on  the  left,  the  caecum,  which  is  still  larger,  is  on  the 
right.  Others  have  thought,  with  Levret,  that  the  insertion  of  the 
placenta,  by  restricting  the  dilatation  ^f  one  particular  portion  of 
the  womb,  might  occasion  lateral  obliquities  to  take  place.  Tn  the 
first  place,  it  is  not  true  that  the  portion  of  the  womb  in  contact  with 


1Q8  OF  TRUE  PREGNANCY. 

the  placenta  enlarges  less  than  the  other  parts  of  the  organ  ;  and 
further,  even  if  we  could  admit  the  fact,  it  would  be  necessary  for 
the  placenta  to  be  attached  almost  always  to  the  right,  which  is  con- 
trary to  what  is  found  to  be  the  case.  Madame  Boivin  attributes 
right  lateral  obliquity,  to  the  excessive  strength  of  the  right  round 
ligament  of  the  womb  ;  but  in  that  case  the  right  angle  of  the  womb 
ought  not  to  be  so  distant  as  it  is  found  to  be  from  the  right  abdomi- 
nal canal.  I  could  more  willingly  admit,  that  being  unable  to  rest 
upon  the  front  of  the  spine,  the  womb  generally  inclines  to  the  right, 
in  consequence  of  the  individuarl's  habit  of  sleeping  upon  that  side, 
and  of  using  the  right  arm  rather  than  the  left ;  but  it  would  be  fur- 
ther necessary  to  prove  that  in  women  who  have  the  opposite  habits, 
the  right  obliquity  is  never  met  with. 

276.  While  the  fundus  and  body  of  the  womb  incline  forwards 
and  to  the  right,  the  cervix  generally  tends  backwards  and  to  the 
left ;  however,  it  would  be  wrong  to  suppose  it  must  be  always  so  : 
the  orifice  may  remain  in  the  centre  of  the  excavation,  although  the 
anterior  or  lateral  obliquities  may  be  very  great,  or  it  may  even  be 
directed  further  backwards  than  is  indicated  by  the  position  of  the 
fundus.  I  have  frequently  found  its  plane  parallel  to  the  anterior 
surface  of  the  sacrum  in  the  last  stages  of  pregnancy,  although  there 
was  not  any  anterior  inclination  ;  it  may  also  be  turned  to  the  right, 
though  the  fundus  is  inclined  to  that  side,  which  is  a  much  rarer  case. 

277.  Thickness  of  the  walls.  Galen,  Paul  iEginetta,  and  Mau- 
riceau  also  have  advanced  that  the  uterus  grows  or  distends  only  at 
the  expense  of  the  thickness  of  its  walls  ;  Riolan,  Deventer,  De  La 
Motte,  and  Roederer,  on  the  other  hand,  have  maintained  that  this 
thickness  increases  during  pregnancy,  while  the  moderns  admit  that 
it  remains  as  it  was  previously  to  fecundation.  Such  discrepancy 
of  opinion  upon  a  fact  easy  to  be  ascertained,  looks,  at  a  first  view, 
very  strange;  but  let  it,  nevertheless,  be  explained  with  reference  to 
the  situation  in  which  the  observers  were  placed.  The  ancients, 
as  they  could  not  open  dead  bodies,  were  compelled  to  reason  from 
analogy  ;  seeing  that  the  coats  of  the  bladder  grow  thin  in  propor- 
tion as  they  become  more  and  more  expanded,  and  that  the  same 
thing,  in  a  large  number  of  animals,  holds  good  as  to  the  uterus  and 
its  horns,  they  did  not  suppose  it  could  happen  otherwise  in  the 
human  species.  Besides,  they  might  found  their  opinions  upon  the 
fact,  that  in  women  dying  with  uterine  hemorrhage  during  labour, 
or  in  the  last  three  months  of  gestation,  in  those  affected  with  hy- 
drometry,  or  in  whom  the  ovum  contains  too  large  a  quantity  of 
amniotic  fluid,  the"»nuscnlar  *oat  of  the  womb  is  indeed  very  thin. 


OF  TRUE  PREGNANCY.  109 

and  sometimes  reduced  to  one  half,  a  thjrd,  and  even  a  quarter  of 
its  natural  thickness. 

Others  might  have  been  induced  to  defend  a  diametrically  oppo- 
site sentiment,  because  during  the  first  eight  days  after  parturition, 
a  period  in  which  more  childbed  women  die  than  in  any  other,  the 
parietes  of  the  womb,  in  contracting,  really  thicken  so  much  as  to  be 
an  inch,  or  even  fifteen  lines  through,  at  the  fundus.  But,  since  nu- 
merous opportunities  have  been  enjoyed  of  interrogating  nature  in 
a  better  way,  hypotheses  founded  on  false  analogies  or  on  excep- 
tionable or  badly  explained  cases,  have  given  way  before  the  truth. 

278.  It  is  now  known  that  the  womb  preserves  nearly  the  same 
thickness  during  the  whole  course  of  pregnancy  as  it  had  when  un- 
impregnated  ;  (I  say  nearly,  for  sometimes  it  is  a  line  or  two  thicker 
or  thinner  ;)  that  this  thickness,  always  greatest  at  the  insertion  of 
the  placenta,  generally  diminishes  from  the  fundus  towards  the  cer- 

.  vix,  where  it  is  frequently  found  to  be  not  more  than  two  or  three 
lines,  or  even  less  ;  that  it  increases  a  little  in  all  parts  of  the  organ 
at  the  same  time,  until  the  third  or  fourth  month,  and  then  remains 
rather  below  its  primitive  limits,  except  the  cervix,  which  at  that 
period,  especially,  grows  thinner,  to  exceed  them  again  in  the 
last  stages  of  pregnancy.  It  is,  therefore,  useless  to  argue  against 
the  opinion  of  Jenty,  who  maintains  that  this  thickness  is  much  more 
apparent  than  real,  and  that  it  is  solely  owing  to  the  accumulation 
of  blood  in  the  uterine  vessels. 

279.  Structure.  In  its  unimpregnated  state,  the  organization  of 
the  womb  seems  to  be  only  incipient;  it  is  perfected,  or  developed,  in 
pregnancy  (169);  its  fibres,  which  were  pale,  dense,  and  inextrica- 
bly tangled,  soften,  become  redder,  and  soon  represent  layers  and 
bundles  easy  to  detect  and  to  follow.  The  cellular  tissue,  which 
was  before  so  firm,  dense,  and  elastic,  relaxes,  becomes  supple, 
and  indeed  resembles  the  common  cellular  tela,  and  in  this  way 
permits  the  other  elements,  which  it  held  in  bondage  as  it  were,  to 
follow  the  impulse  that  animates  the  whole  womb.  The  arterial 
branches  folded  upon  each  other  a  thousand  times,  like  the  vas  de- 
ferens, and  bridled  in  this  condition  by  dense,  elastic  laminae,  cede 
to  the  general  relaxation,  and  gradually  become  lengthened  ;  their 
angles,  at  first  so  sharp,  with  their  doublings,  grow  blunter,  enlarge, 
and  at  last  exhibit  only  certain  zigzags  of  greater  or  less  depth, 
tortuosities  which  do  not  impede  the  circulation,  and  their  calibre, 
before  the  end  of  gestation,  comes  to  be  double,  triple,  and  even 
quadruple  its  diameter  previous  to  fecundation. 

280.  The  veins  undergo  the  same  metamorphoses  :  already,  in  the 
natural  state,  larger  and  less  tortuous,  they  enlarge,  and  are  developed 


110  OF  TRUE  PREGNANCY. 

still  more  rapidly  than  the  arteries  ;  at  term  they  are  observed  to 
furrow  the  fleshy  layer  in  every  direction,  and  form  a  net-work  which 
in  some  measure  separates  it  into  two  planes.  They  are  large 
enough  to  admit  a  goose  quill,  and,  in  some  instances,  even  the  end 
of  the  little  finger  ;  near  the  mucous  membrane  they  dilate  so  as  to 
constitute  cones  with  inverted  bases ;  cones  described  by  Astruc, 
under  the  name  of  uterine  sinuses,  but  which  Haller  restored  to 
their  proper  nature  by  denominating  them  venous  sinuses;  and  to 
which  Hunter  thinks  no  particular  name  should  be  given. 

281.  The  lymphatic  vessels  are,  according  to  Cruikshank,  so 
amplified  that  they  may,  by  injecting  them  with  mercury,  be  made  as 
large  as  crow-quills,  and  to  form  a  kind  of  coating  of  silver  to  the  sur- 
face of  the  womb  ;  the  nerves  themselves,  according  to  Hunter,  also 
increase  sensibly  in  size  ;  which  accounts  for  certain  alterations  of 
function  we  shall  have  occasion  to  treat  of  in  a  subsequent  page. 

282.  The  mucous  membrane,  the  existence  of  which  it  is  so  dif- 
ficult to  demonstrate  in  the  uninlpregnated  state,  becomes  more 
evident,  redder,  more  villous  ;  distinct  shreds  of  it  can  be  separated; 
the  folds  which  it  forms  for  the  purpose  of  enclosing  the  ridges  of 
the  cervix,  relax  and  disappear,  but  not  until  the  last  half  of  preg- 
nancy ;  the  serous  coat  also  is  far  from  being  unaffected  by  all  these 
changes,  and  Bichat  was  evidently  mistaken  when  he  asserted  that 
the  peritoneum,  like  the  other  diaphanous  membranes,  possesses 
no  extensibility.  At  the  end  of  pregnancy,  the  meso-rectum  re- 
mains ;  the  broad  ligaments,  and  other  folds,  though  tightened,  are 
not  effaced,  yet  lose  some  of  their  proportional  dimensions,  and  even 
somewhat  of  their  absolute  dimensions.  Besides,  admitting  that 
they  do  become  completely  unfolded,  their  laminse  would  be  insuffi- 
cient to  cover  a  circumference  of  twenty-six  inches.  It  is  evident, 
then,  that  the  serous  coat  increases  in  the  same  proportion  as  the 
fleshy  coat  of  the  womb  ;  that  it  is  extensible,  and  remains  in  con- 
tact with  the  same  points  of  the  subjacent  layers,  from  the  com- 
mencement to  the  end  of  gestation.  I  have  even  remarked,  as  M. 
Ristelhueber  has,  that,  instead  of  becoming  thinner,  it  rather  in- 
creases in  thickness,  and  that  its  adherenccs  scarcely  relax  at  all 
while  it  is  undergoing  this  amplification. 

283.  Functions  and  properties.  In  proportion  as  the  uterine 
vessels  deploy  themselves,  the  blood  is  determined  thither,  and  at 
last  the  womb,  like  a  sponge,  is  gorged  with  that  fiuid  ;  however, 
the  menses  are  suppressed  as  soon  as  fecundation  is  effected,  and 
some  physiologists  have  attributed  to  this  circumstance  most  of  the 
modifications  which  are  then  experienced  by  the  womb ;  but  we 
cannot  adopt  such  an  opinion,  for  the  same  changes  arc  observed 


OF  TRUE  PREGNANCY.  Ill 

in  women  who  continue  to  be  subject  to  a  periodical  discharge 
during  pregnancy,  and  where  the  uterus  is  distended  by  a  polypus, 
while  they  are  not  met  with  in  a  case  of  simple  amenorrhcea.  Tra- 
versed by  larger  nerves,  and  receiving  a  larger  supply  of  vivifying 
fluids,  the  uterus  enjoys  a  liveUer  sensibility  :  in  the  unimpregnated 
state  it  may  be  touched,  struck,  pressed  upon,  without,  so  to  speak, 
causing  the  woman  to  feel  any  pain  ;  during  the  growth  of  the  ovum, 
on  the  contrary,  the  least  jar,  the  least  touch  of  the  foetus  are  in- 
stantly felt  by  the  mother  ;  both  its  sensibihty  and  contractility  are 
of  a  grade  almost  as  high  as  that  of  the  organs  of  relation. 

284.  To  explain  the  extraordinary  development  of  the  uterine 
cavity,  the  ancients  taught  that  the  ovum  dilates  it  by  growing,  just 
as  we  can  dilate  a  glass  tube  by  blowing  Into  it,  as  we  distend  a 
bladder  by  filling  it  with  a  fluid  or  air,  or  as  we  can  spread  out  a 
ball  of  soft  wax.  Puzos  has  not  rendered  this  hypothesis  more  sus- 
tainable, by  calHng  to  its  support  the  laws  observed  by  fluids  in  trans- 
uding from  without  to  the  innei  side  of  any  inert  vessel ;  for  as,  in 
physics,  the  force  of  impulsion  of  fluids  is  measured  by  the  heightn 
and  thickness  of  the  column,  it  is  clear  that  in  this  case,  the  distend- 
ing eflbrt  would  increase  in  an  inverse  ratio  to  the  resistance ;  that, 
from  being  very  feeble  at  the  beginning,  when  the  density  of  the 
organ  is  considerable,  it  would  at  the  close  be  doubled  ten  times  to 
overcome  a  less  difficulty.  Would  it  be  any  better  to  say,  with  Van 
Helmont,  that  the  womb  dilates  spontaneously  under  the  influence 
of  a  bias  meteorisant,  or  to  admit,  with  Levret  and  the  moderns,  that 
like  the  heart  and  the  erectile  tissues,  it  grows  actively^  and  by  the 
mere  force  of  its  vital  properties  ?  But  in  reasoning  thus,  the  fact 
is  explained  without  indicating  the  cause.  It  is  at  least  certain  that 
the  dilating  force,  altogether  foreign  to  the  product  of  conception, 
exists  in  the  gestative  organ  itself:  a  circumstance  that  beyond 
question  proves  this  to  be  the  case,  is,  that  in  preternatural  preg- 
nancies, as  remarked  by  Levret,  Bertrandi,  Meckel,  Chaussier,  &c. 
the  uterine  cavity,  though  empty,  dilates  as  it  does  in  an  ordinary 
gestation. 

285.  To  explain  this  dilatation,  it  is  useless,  with  Malpighi,  to  refer 
to  a  fermentative  principle  contained  in  the  semen,  or  with  Blumen- 
bach,  to  a  peculiar  vital  action  ;  the  turgescence  occasioned  by  fe- 
cundation, and  kept  up  by  the  ovum,  aff()rds  a  very  satisfactory  rea- 
son for  it :  the  congestion,  of  which  the  womb  is  the  seat,  invites  to 
it  an  excess  of  nutrition  ;  tiic  new  molecules  incessantly  deposited 
there,  necessarily  elongate  its  fibres  ;  the  vascular  channels  are  both 
uncoiled  and  enlarged  at  the  same  time,  and  as  this  unfolding  and 
elongation  cannot  take  place  without  ijpcreasiug  the  extent  of  the 


112  OF  TRUE  PREGNANCY. 

curves  or  circles  represented  by  each  fibre  and  vessel  in  the  organ, 
it  follows  that  tlie  amplification  of  its  cavity  must  be  an  inevitable 
consequence  of  the  augmented  nutrition  of  its  parietes. 

286.  Moreover,  the  ovum  and  the'womb  enlarge  both  together  ; 
and  though  the  end  or  function  of  the  thing  contained  is  not  to  en- 
force the  distention  of  that  which  contains  it,  it  at  least  serves  to 
support  its  parietes,  and  to  keep  up  its  due  measure  of  irritation. 
In  this,  as  in  all  other  cases,  nature  finds  the  means  of  multiplying 
effects  without  augmenting  the  number  of  causes. 

287.  Appendages  of  the  uterus.  The  changes  effected  in  the 
position,  size,  and  weight  of  the  womb  will  of  necessity  occasion 
some  alterations  in  the  disposition  of  the  circumjacent  parts. 

288.  In  consequence  of  the  depression  of  the  cervix  during  the 
first  months,  the  vagina  becomes  shorter  and  wider ;  at  a  later  pe- 
riod, being  drawn  upwards  along  with  the  uterus,  it  becomes  elon- 
gated, and  at  length  forms  a  kind  of  cone  with  the  apex  at  the  vulva. 
By  means  of  the  fluids  it  imbibes  it' becomes  softened  ;  its  anterior 
and  posterior  columns  sometimes  acquire  a  very  considerable  size, 
especially  near  their  lower  ends. 

289.  The  Fallopian  tubes ^  retained  by  the  broad  ligaments 
against  the  sides  of  the  womb,  enlarge,  become  redder,  more  vascu- 
lar, and,  as  it  were,  spongy  on  the  inner  surface  of  their  funnel 
shaped  portion. 

290.  The  ovaries,  which  are  depressed  in  the  same  way,  also  in- 
crease in  size  ;  their  vessels  dilate,  sometimes  become  varicose,  so  as 
even  to  burst,  and  occasion  a  fatal  hemorrhagy. 

The  fibres  of  the  round  ligaments  are  better  expressed,  enlarged  and 
redder,  so  that  at  the  period  of  labour,  they  compose  two  real  muscu- 
lar cords,whose  contraction  is  in  certain  cases  so  evident,  that  I  have 
in  three  difierent  women  observed  it  myself,  and  also  pointed  it  out 
to  several  persons  during  the  contraction  of  the  womb  for  expelling 
the  after  birtii. 

291.  The  bladder  rkes  above  the  superior  strait ;  the  urethra  is 
concealed  behind  the  symphysis  of  the  pubis,  becomes  almost  verti- 
cal, its  orifice  retreats  under  the  summit  of  the  pubic  arch,  and  the 
introduction  of  the  catheter  in  pregnant  women,  is  thus  rendered 
more  difficult ;  it  may  also  happen  that  the  urinary  bladder,  being 
more  forcibly  compressed  above  than  below  its  fundus,  may  project 
against  the  upper  part  of  the  vagina,  making  a  tumour  there  of 
which  I  iiavo  often  met  with  cases  in  the  latter  half  of  gestation. 

292.  The  rectum  being,  as  it  were,  strangulated  above,  and  no 
longer  receiving  any  impulsion  from  the  diaphragm,  becomes  dis- 


OP  TRUE  PREGNANCY.  113 

tended  with  stercoraceous  matters,  and  in  that  way  interferes  with 
the  form  of  the  posterior  wall  of  the  vagina. 

293.  The  small  intestines,  being  raised  upwards  by  the  fundus  of 
the  uterus,  in  front  of  which  they  are  sometimes  partially  placed,  may 
be  in  that  way  so  compressed  as  to  occasion  colic  pains  of  a  more 
or  less  violent  character ;  at  other  times  their  most  movable  por- 
tions engage  in  the  recto-vaginal  excavation,  where  they  are  liable  to 
be  strangulated  and  give  rise  to  very  serious  affections  ;  but  they  are 
most  frequently  thrust  towards  the  lumbar  regions,  or  else  mount 
directly  up,  pressing  against  the  arch  of  the  colon,  the  stomach  and 
liver. 

The  diaphragm  itself  being  pushed  upwards  into  the  thorax, 
whose  base  it  enlarges,  while  its  vertical  diameter  is  lessened,  is  in 
some  degree  hindered  from  executing  its  contractile  movement. 

294.  The  skin  on  the  lower  part  of  the  beljy  becomes  thinner,  is 
covered  with  whitish  blemishes  and  streaks,  arranged  in  zigzag  or 
curved  lines,  with  the  convexity  downwards  ;  its  meshes  enlarge  like 
that  of  a  piece  of  stuff  that  yields  upon  being  stretched,  without, 
however,  tearing.  After  the  lying-in  it  appears  to  be  covered  all 
over  with  reticulated  scars,  and  becomes  wrinkled  or  covered  with 
plaits  ;  in  short  women,  as  observed  by  M.  Desormeaux,  and  I  will 
add,  in  those  where  the  abdomen  attains  to  a  very  considerable  size, 
this  state  of  the  skin  is  propagated  as  far  as  the  thighs  and  breech. 

295.  The  aponeuroses  become  frayed  ;  the  inguinal  ring  enlarges 
a  little,  but  the  linea  alba  undergoes  the  greatest  changes,  because 
it  is  more  peculiarly  charged  with  resisting  the  weight  of  the  womb 
and  the  viscera  ;  instead  of  one  inch,  it  sometimes  is  four  inches 
wide  at  its  middle  ;  towards  the  end  of  pregnancy  we  find  in  its 
place  nothing  more  than  a  tissue  or  net- work  with  meshes  more  or 
less  supple. 

296.  The  navel  opens  a  little,  grows  more  salient  and  thinner, 
which  renders  the  occurrence  of  umbilical  hernia  very  easy.  In  a 
great  many  women  there  is  such  a  separation  of.  the  aponeurotic 
fibres  upon  the  median  line,  that  it  seems  as  if  it  were  pierced  with 
a  lozenge-shaped,  or  elliptical  opening,  the  ends  of  which  approach 
sometimes  nearer,  sometimes  less  near  to  the  epigastrium  or  pubis. 
Further,  in  this  case  there  is  left,  after  the  labour  is  over,  an  oblong 
tumour,  a  kind  of  eventration,  which  is  sometimes  increased  by  sub- 
sequent pregnancies  to  such  a  degree,  as  to  permit  the  womb  to 
turn  very  much  over  in  front,  above  the  superior  strait. 

297.  The  pressure  exercised  by  the  womb  upon  the  vqsscI^  of 
the  pelvic  excaxAtipn  necessarily  impedes  the  venous  circulation  of 
the  surrounding  parts;  the  external  organs  of  generation,  too,  and 

P 


114  OF  TRUE  PREGNANCY. 

the  lower  limbs,  are  often  seen  to  be  infiltrated,  covered  with  varices, 
and  affected  with  considerable  pain;  pains  that  may  depend  upon  the 
compression  of  nerves  belonging  to  the  lumbar  and  sacral  plexuses. 

298.  The  pelvis  relaxes,  and  its  articulations,  so  firm  and  solid, 
change  so  much,  as  in  some  women  to  become  quite  movable. 
Avicenna,  Aetius,  Fernel,  and  most  of  the  ancients  had  doubtless  ob- 
served it,  for  they  placed  rigidity  of  the  symphyses  among  the  causes 
of  difficult  labour  :  this  opinion  however  was  pretty  generally  aban- 
doned about  the  time  of  Pare  ;  for  S.  Pineau,  vigorously  opposed  by 
the  surgeons  of  Paris  for  having  maintained  it,  never  could  convince 
them  of  it,  until  he  exhibited  the  body  of  a  newly  delivered  woman 
who  had  been  executed.  Since  then,  Bertin  and  Bouvart,  in  a  cele- 
brated thesis ;  Smellie,  Levret,  Plessman,  Piet,  Desault,  M.  Boyer, 
Baudelocque,  Beclard,  Chaussier,  Madame  Boivin,  &c.  have  ad- 
mitted the  softening  of  the  pelvic  articulations  :  some  as  a  constant 
occurrence  ;  others  as  an  exception  ;  some  as  a  state  proper  to 
facilitate  parturition,  as  a  wise  precaution  of  nature ;  others  as  a 
dangerous  disease.  At  present  the  existence  of  the  fact  cannot  be 
doubted,  and  all  the  questions  relating  to  this  long  debated  point  are 
of  easy  solution.  Reason  indicates,  and  observation  proves  that  the 
ligamentous  bands  of  the  pelvis  become  more  soft  and  supple  in 
raany  pregnant  women  ;  and  that,  in  common  with  all  the  surround- 
ing parts,  they  contain  a  larger  quantity  of  fluid  ;  but  it  is  impossible 
for  such  an  afflux  of  fluids  to  take  place  without  the  articular  surfaces 
being  separated.  This  process,  however,  is  so  moderate  in  a  ma- 
jority of  cases,  that  neither  the  woman  nor  the  accoucheur  perceive 
it.  Smellie  has  seen  it  carried  to  such  an  extent  that  the  bones 
could  be  made  to  ride  over  each  other ;  Denman  also  mentions  cases 
of  considerable  separation  ;  Madame  Boivin  says  it  is  not  uncommon 
to  find  a  distance  of  four,  six,  eight,  ten,  and  even  twelve  lines  be- 
tween the  pubes,  and  naturalists  are  aware  that  in  some  of  the  mam- 
miferx,  the  bones  of  the  pelvis,  too  narrow  to  permit  the  birth  to 
take  place,  separate  so  widely  during  gestation,  as  to  be  in  a  manner 
lost  in  the  soft  parts. 

299.  In  these  cases  of  extreme  sofl:cning,  standing  and  walking, 
which  in  some  individuals  are  both  fatiguing  and  painful  at  the  close 
of  pregnancy,  may  produce  inflammation  and  suppuration  of  the  sym- 
physes, numerous  examples  of  which  are  upon  record ;  in  these 
cases  too  it  is  right,  as  Baudelocque  teaches,  to  class  their  mobility 
among  the  pathological  alterations  :  on  the  other  hand,  we  may  con- 
ccivfi|that  in  a  slightly  contracted  pelvis,  such  a  softening  may  to  a 
cerflnn  extent  have  a  beneficial  effect  upon  the  labour,  as  has  been 
asserted  by  several  authors ;  but  for  promoting  this  softening,  is  it 


OF  TRUE  PREGNANCY.  g'S 

proper,  in  accordance  with  Pineau,  to  repose  any  confidence  upon 
the  action  of  baths,  cataplasms,  and  other  means  of  the  same  nature  ? 
Is  it  possible,  without  any  bad  effect,  to  increase  it  by  mechanical 
efforts,  such  as  dilating  efforts  for  example  ?  Can  we  believe  with 
Denman  and  others,  that  the  pressure  exerted  by  the  child's  head 
has  something  to  do  with  its  production,  when  the  labour  is  violent, 
and  yet  progresses  slowly  ? 

According  to  Baudelocque,  the  ligaments  alone  share  in  this  ope- 
ration ;  MM.  Piet  and  Chaussier  are  wrong  in  teaching  that  the 
cartilaginous  plates  are  equally  concerned  in  it. 

The  symphysis  of  the  pubis,  being  in  almost  all  respects  similar  to 
the  articulation  of  the  bodies  of  two  vertebras,  explains  why  the  soft- 
ening affects  it  more  frequently,  and  always  to  a  greater  degree 
than  the  posterior  symphyses  ;  and  how  it  happens  that  in  a  majority 
of  women  who  have  borne  children,  its  surfaces  are  commonly  rather 
more  distantly  separated  than  they  were  before  pregnancy  took 
place. 

300.  The  consistency  even  of  the  bones  of  the  pelvis  is  some- 
times so  altered,  that  they  become  flexible.  Weidman  relates  a  re- 
markable instance  of  this  kind  :  the  inferior  strait  was  so  contracted,' 
that  the  caesarian  operation  appeared  to  be  indispensably  necessary; 
but  in  attempting  to  pass  up  his  hand,  he  perceived  that  the  ischia 
and  the  pubic  arch  yielded  like  cartilage,  and  the  labour  terminated 
without  an  operation.  M.  Hofmeister  has  lately  published  a  case 
nearly  similar,  and  not  less  curious.  According  to  Burns  and  other 
English  accoucheurs,  this  state  of  things  often  exists  as  a  symptom 
of  the  dangerous  disease  they  describe  under  the  title  ot  malacosteon. 

§.  II.  Sympathetic  phenomena,  and  rational  signs. 

301.  The  numerous  material  modifications  that  have  just  been 
enumerated,  act  more  or  less  upon  the  rest  of  the  system,  and  give 
rise  to  what  are  by  agreement  denominated  the  general.,  common, 
rational,  vague,  uncertain,  and  doubtful  signs  of  gestation. 

302.  It  is  a  common  notion,  long  ago  inculcated  by  Hippocrates 
and  Galen,  that  a  fruitful  copulation  is  accompanied  with  much  live- 
lier enjoyment  than  an  ordinary  coitus,  and  that  it  is  felt  at  the  same 
moment  by  both  the  parties.  According  to  Aristotle  the  copulative 
organ  of  the  male  is  withdrawn  less  moist  than  commonly  from  the 
female  organs,  and  the  seminal  fluid  does  not  escape  from  them. 
Immediately  after  coition  the  two  beings  fall  into  a  state  of  languor, 
of  weakness,  of  uncommon  sadness  ;  the  woman  feels  a  disposition 
to  faintness,  to  syncope,  to  have  horripilation,  colic,  and  a  sort  of 
vermicular  motion  which  seems  to  proceed  from  the  womb  and  pass 


11^  OF  TRUE  PREGNANCY. 

to  the  iliac  fossas  or  ilancs  ;  borborygmi,  first  in  the  uterus,  which 
seems  to  bo  full  of  gas,  and  then  throughout  the  whole  abdomen,  and 
sometimes  a  general  shivering,  beginning  in  the  abdomen,  complete 
the  series  of  symptoms  which  announce  that  fecundation  has  taken 
place. 

303.  This  first  condition  is  succeeded  by  pregnancy,  properly  so 
called.  The  eyes  lose  their  vivacity,  their  brilliancy,  have  an  ex- 
pression of  languor,  and  seem  to  sink  into  their  orbits ;  the  eyelids 
grow  dark  and  are  surrounded  with  a  blackish,  livid,  or  leaden  circle; 
the  nose  grows  sharper  and  longer  ;  the  mouth  widens  by  the  sepa- 
ration of  its  corners ;  all  the  features  of  the  face  seem  to  retire 
backwards,  which  renders  the  chin  more  prominent ;  ^.heface  be- 
comes pale,  is  covered  with  spots  of  various  sizes  and  numbers, 
sometimes  reddish,  or  of  a  more  or  less  deep  brown  ;  sometimes, 
but  more  rarely,  of  a  dead  or  milk  white  colour  ;  in  a  word,  it  be- 
comes masked. 

The  neck  swells,  becomes  softer,  and  is  the  seat  of  a  congestion, 
which,  according  to  Diogenes,  was  formerly  indicated  by  Democritus, 
and  which  Catullus  has  mentioned  in  the  following  lines : 

Non,  illam  nutrix,  orienle  luce,  revisens, 
Hesterno  collutn,  poterit  circumdare  filo  ; 

a  congestion  which  Dumas  says  he  has  positively  observed.  The 
breasts  enlarge,  become  more  tender,  firmer  ;  sometimes  a  few  drops 
of  whitish  serosity  can  be  extracted  from  them ;  the  nipple  rises  and 
is  more  prominent ;  the  areola  enlarges  and  grows  visibly  browner  ; 
the  delicacy  of  their  tegumentary  layer  increases,  and  they  also  occa- 
sionally exhibit  some  whitish  stains,  analogous  to  those  on  the  face. 

304.  The  pulse,  at  first  embarrassed,  acquires  a  greater  degree 
of  frequency,  and  then  of  force  and  hardness  ;  it  becomes  larger, 
fuller,  sometimes  irregular,  and  somewhat  bounding,  quick  and 
feverish  ;  towards  the  term  of  labour,  it  is  found  to  be,  says  Bordeu, 
convulsive-like,  intermittent  and  corded  ;  in  fine,  the  artery  seems 
to  be  more  tense,  beats  with  more  frequency  and  velocity  ;  the  cir- 
culation being  more  active,  hemorrhages  are  commoner  and  more 
dangerous  ;  blood  drawn  from  a  vein,  or  escaping  accidentally  from 
the  organs,  is  found  to  be  covered  with  a  sizy  coat,  of  variable 
thickness,  according  as  the  fibrine  or  crassamentum  happens  to  be 
above  or  below  the  natural  proportions.  The  temperature  of  the 
body  rises,  and  onal>lcs  pregnant  women  to  bear  cold  better  than 
others  ;  the  insensible  transpiration  is  also  more  abundant,  and  at 
the  commencement  yields  an  odour  of  prolific  matter,  but  which 
afterwards  becomes  acrid  or  of  a  peculiar  nature.     The  urine  flows 


» 


OF  TRUE  PREGNANCY.  117 

more  abundantly,  is  cloudy,  and  contains  a  larger  sediment ;  all  the 
secretions  are  more  energetically  effected  ;  the  saliva,  in  particular, 
is  often  furnished  in  great  quantity,  so  that  some  women  are  attacked 
with  a  real  ptyalism.  The  li^^er^  being  deranged  in  its  secretions,  is 
said  to  occasion  the  stains  or  ephelides  of  the  face  and  skin. 

305.  The  sense  of  taste  and  the  digestion  are  still  more  specially 
perverted  ;  anorexia,  nausea,  and  even  vomiting  supervene,  and  are 
frequently  followed  with  a  complete  loss  of  appetite ;  the  woman 
now  desires  for  food  nope  but  the  most  singular  and  sometimes  dis- 
gusting objects.  At  one  while  her  greatest  happiness  is  to  eat  clay, 
ashes,  lime,  or  to  craunch  charcoal ;  at  another  she  places  her  de- 
light in  half  putrid  meat,  spiders,  or  other  unclean  animals :  in 
general  she  is  displeased  with  fat,  and  an  animal  regimen  ;  fruits  and 
vegetables  suit  her  better ;  some  ardently  desire  sour  drinks,  and 
love  none  but  food  prepared  with  vinegar,  as  salad,  &c. 

306.  This  state  of  inappetency  and  disgust  is  succeeded,  after  the 
few  first  months,  by  a  very  decided  appetite,  in  some  cases  almost 
voracious,  by  easy  digestion,  fondness  for  wine  and  other  spirituous 
drinks ;  but  in  the  last  third  part  of  pregnancy,  the  digestive  func- 
tions again  become  disturbed,  doubtless  because  the  stomach,  being 
at  that  period  too  small,  can  only  take  in  very  small  quantities  of 
food  and  drink. 

307.  The  moral  condition  of  the  female  is  also  subject  to  pretty 
numerous  changes:  some  women,  naturally  gay,  good  tempered, 
and  amiable,  become  sad,  mechancholy,  cross,  unsociable,  and  vice 
versa.  In  a  good  many  women,  the  passioni,  although  previously 
moderate,  acquire  an  extraordinary  violence,  cannot  be  subdued, 
and  cause  the  commission  of  the  most  atrocious  crimes ;  in  others, 
there  are  merely  some  singular  desires,  such  as  to  eat  a  particular 
kind  of  fruit  or  meat  or  game,  or  some  particular  dish,  no  matter 
at  what  price;  an  irresistible  tendency  to  steal  objects  of  small 
value,  or  for  which  they  have  no  use,  and  corruption  of  their  man- 
ners or  character.  There  are  some  whose  wit  is  never  more  lively, 
more  penetrating,  more  agreeable ;  while  others  fall  into  a  sort  of 
stupidity  and  apathy  quite  unnatural  in  them.  In  general  the  activity 
of  the  intellectual  faculties  is  augmented,  whether  in  the  whole,  or 
only  in  part ;  in  one  case  the  memory,  or  a  taste  for  the  arts  or 
sciences,  are  modified ;  in  others  the  judgment  becomes  exquisite, 
or  the  imagination  is  exalted  to  such  a  degree,  that  some  women 
have,  during  their  pregnancy,  attained  to  a  surprising  degree  of  per- 
fection in  those  works  of  genius,  those  arts  or  sciences,  which  they 
had  previously  cultivated  with  indifference  and  without  success  ; 
some  lose  their  senses  and  become  crazy,  always  at  the  same  periods 


118  OF  TRUE  PREGNANCY. 

of  their  pregnancy ;  others  are  seen  in  whom  mania  never  disap- 
pears, and  who  never  become  composed  except  during  this  function. 

308.  Many  diseases  supervene,  are  suspended,  or  disappear ; 
sometimes  adontalgia,  without  any  caries  of  the  teeth,  is  renewed 
every  time  the  woman  becomes  pregnant;  sometimes" neuralgia, 
whether  suborbital,  facial,  or  of  any  other  sort ;  chorea  or  St  Vitus's 
dance ;  convulsions,  or  other  motions,  hysterical  or  epileptiform  ;  in 
other  cases,  pulmonary  consumption  of  a  very  advanced  stage 
seems  to  retrograde,  or  even  gives  place  to  a  highly  flourishing 
state  of  health  ;  a  pretty  considerable  number  of  different  diseases, 
such  as  chronic  or  obscure  inflammation  of  the  lungs  or  digestive 
passages,  and  serious  and  profound  organic  lesions  are  afiected  in 
the  same  manner.  But  although  it  is  true  that  after  parturition 
some  of  the  affections  that  are  happily  modified  by  gestation  do  not 
return,  it  is  but  too  certain  that  a  major  part  of  them  thenceforth 
progress  towards  a  fatal  termination  with  frightful  rapidity. 

309.  Such  is  the  series  of  sympathetic  phenomena  noticed  in 
pregnant  women  by  accoucheurs :  it  has  been  seen  that  they  are 
numerous  ;  but  unhappily,  every  one  of  them  may  exist ;  they  may 
even  be  met  with  altogether,  without  the  patient's  being  pregnant ; 
while  on  the  other  hand,  pregnancy  often  takes  place  without  giving 
rise  to  them.  Besides,  how  can  we  rely  upon  those  that  depend 
upon  sensations  experienced  during  or  immediately  after  coition  ? 
Women,  like  all  the  rest  of  the  human  race,  easily  believe  what  they 
desire,  and  are  willing  to  conceal  even  from  themselves  what  they 
dread.  They  therefore  will  or  will  not  experience  such  and  such 
symptoms,  accordingly  as  they  do  or  do  not  wish  to  be  pregnant. 
How  can  we  subsequently  recognize  among  the  disturbances  or  dis- 
orders of  the  mind  that  which  appertains  to  pregnancy,  and  distin- 
guish it  from  that  which  is  occasioned  by  perverseness,  or  that  which 
depends  upon  actual  disease  ? 

310.  Be  this  as  it  may,  there  are  a  great  many  cases  in  which,  by 
proper  attention,  an  able  accoucheur  can  make  excellent  use  of  the 
rational  signs,  in  forming  his  opinion.  For  example,  when  the  mask 
on  the  face  is  rapidly  manifested  in  a  woman  who  has  never  had  it 
before,  who  lives  in  a  large  city,  and  is  not  exposed  to  th6.heat  of 
the  sun,  it  becomes  a  very  probable  sign  of  pregnancy.  The  same 
may  be  said  of  the  violet  circle  round  the  eyes,  and  of  the  swelling 
and  sensibility  of  the  breasts,  when  they  are  independent  of  the  men- 
strual function  ;  of  the  nausea,  ptysalism,  and  disordered  digestion, 
perversion  of  the  desires  and  appetite,  when  they  are  not  results  of  a 
morbid  suppression  of  the  catamenial  discharge.  As  to  the  odour 
given  out  by  the  skin  ;  as  to  the  perspiration,  the  increased  tempera- 


OF  fRUE  PREGNANCY.  119 

ture,  the  condition  of  the  pulse,  the  urine,  the  Colour  of  the  nipple 
and  its  areola,  the  size  of  the  neck,  the  changes  in  the  aspect  of  the 
face,  &.C.  their  existence  is  too  variable,  too  fugacious,  or  depends 
upon  too  many  different  causes,  or  they  are  of  too  difficult  determi- 
nation, to  permit  us  to  repose  the  least  confidence  in  them.  They 
are  merely  so  many  resources  which  the  learned  and  Upright  physi- 
cian abandons  to  the  shameless  quack,  or  to  the  credulous  ignorant 
vulgar  who  are  duped  by  them.  Upon  the  whole,  the  rational  signs, 
when  united  in  a  certain  number,  anjj  properly  weighed,  most  com- 
monly suffice  to  make  us  believe  in  the  existence  of  gestation,  but 
never  to  give  us  a  mathematical  certainty  of  it,  to  warrant  us  in 
affirming  to  it  before  a  court,  even  although  in  addition  to  these 
there  should  be  a  suspehsion  of  the  periodical  flux. 

311.  Menses.  However,  in  women  who  have  no  interest  in  de- 
ceiving us,  the  last  mentioned  phenomenon  deserves  the  greatest  at- 
tention ;  it  is  the  most  conclusive,  and  sometimes  the  only  one  to  be 
met  with  ;  but  inasmuch  as  it  is  frequently  the  cause  or  the  effect  of 
a  great  number  of  affections  of  more  or  less  importance,  and  wholly 
independent  of  pregnancy,  it  is  not  an  easy  matter  to  interpret  it 
correctly.  If  it  happen  suddenly,  without  being  preceded  by  any 
accident  or  disease  that  might  account  for  it,  and  in  a  woman  who 
is  commonly  very  regular,  it  may  constitute  an  almost  certain  sign 
of  pregnancy,  while  in  the  contrary  condition,  its  value,  always  much 
lessened,  can  be  determined  only  by  a  circumspect  and  experienced 
practitioner.  I  have  no  occasion  to  remark  that  it  is  of  no  valuje 
where  pregnancy  occurs  before  the  first  eruption  of  the  menses. 
Further,  it  is  well  known,  that  a  woman  whose  menses  have  been 
for  some  time  suppressed,  either  from  disease  or  merely  from  the 
progress  of  age,  may  become  pregnant ;  that  some  women  are 
never  regular  except  when  they  are  pregnant  j  and  that  the  continu- 
ance of  the  menses  after  fecundation  is  found  occasionally  to  be  al- 
most epidemic,  or  at  least,  much  more  frequent  in  some  years  than 
in  others. 

312.  Size  of  the  BeUy.  The  enlargement  of  the  abdomen  in  a 
woman  old  enough  to  be  fecundated,  ordinarily  suflSces  with  the  pub- 
lic, to  make  them  presume  that  she  is  pregnant.  It  is  otherwise 
with  physicians.  It  is  occasioned  by  so  many  diseases,  that  it  ought 
in  this  respect  to  be  classed  in  the  same  category  as  the  suppres- 
sion of  the  menses.  Nevertheless,  its  ordinary  rate  of  progress  is 
such  as  to  yield  a  very  important  sign,  and  one  which,  alone,  is,  in  a 
good  many  cases,  sufficient  to  render  it  certain  that  there  is  preg- 
nancy. 


120  OF  TRUE  PREGNANCY. 

313.  The  belly  often  tumefies  or  swells  by  insensible  degrees  from 
the  first  week  after  conception  has  taken  place ;  it  afterwards  dimi- 
nishes or  is  even  flattened  about  the  beginning  of  the  second  month  ; 
whence  the  common  proverb,  a  ventre  plut,  enfant  il  y  a.  It  soon 
afterwards  grows  again  in  a  regular  manner,  and  never  stops  until  the 
term  of  parturition.  At  first  it  projects  along  the  median  line  and 
lower  part  of  the  hypogastrium  ;  while  the  navel  seems  to  sink  be- 
neath its  natural  level.  Until  the  fourth  month,  the  iliac  regions  ap- 
pear to  grow  hollow  instead  of  yrojccting  in  proportion  with  the  hy- 
pogastrium. About  the  end  of  the  third  month,  the  navel  approaches 
towards  the  level  of  the  skin,  which  it  soon  surpasses,  so  as  in  some 
women  to  form  a  protuberance  of  an  inch  or  two,  in  the  course  of  the 
fifth,  sixth  or  seventh  month.  Upon  the  whoFe,  the  special  character 
of  a  pregnant  woman's  abdomen  is  that  it  grows  from  below  upwards, 
and  remains  a  long  time  flattened  on  its  sides,  although  its  middle 
portion  already  projects  considerably.  I  shall  have  further  occasion 
to  advert  to  this  point  when  I  point  out  the  means  of  distinguishing 
true  pregnancy  from  the  afiections  with  which  we  are  liable  to  con- 
found it. 

§.  III.  Sensible  signs. 

314.  The  sensible  signs  of  pregnancy  are  obtained  by  means  of 
the  touch,  or  of  auscultation,  and  from  the  material  changes  effected 
in  the  womb. 

315.  2' fie  touch.  The  introduction  of  one  or  two  fingers  into 
the  vagina,  while  the  other  hand  is  applied  to  the  front  of  the  abdo- 
men,is  called,  in  tokology,  the  touch.  Recourse  is  had  to  it  for  the 
purpose  of  ascertaining  the  diseases  of  the  vulva,  of  the  vagina,  the 
womb,  the  bladder,  the  rectum,  and  all  the  organs  contained  within 
the  pelvic  cavity  ;  to  learn  the  good  or  bad  conformation  of  the  pel- 
vis, the  nature,  species,  and  degree  of  its  contraction  ;  but  especially 
for  appreciating  the  modifications  of  the  cervix  uteri,  either  in  re- 
gard to  its  size,  its  consistence,  position,  length  or  temperature ; 
and  the  weight,  form,  extent,  situation^and  dimensions  of  the  womb 
itself  during  the  course  of  pregnancy. 

316.  The  touch  has  always  been  looked  upon  as  the  con:q)ass  of 
the  accoucheur ;  but  tiiis  has  not  hindered  some  persons,  Puzos 
among  others  (122),  frbm  vigorously  objecting  to  its  employment. 
Rousscl  says  that  "  accoucheurs  ought  to  expunge  from  their  books 
the  impertinent  directions  that  they  give  concerning  the  touch.'' 
According  to  him  the  operation  is  too  alarming  to  the  modesty  of  a 
rosi)octublc  woman,  too  contrary  to  good  morals,  and  gives  signs 
too  vague  for  it  ever  to  lie  had  recourse  to.     But  Roussel  speaks 


OF  TRUE  PREGNANCY.  121 

here  more  like  a  rhetorician  than  a  physician  ;  his  arguments,  drawn 
from  its  abuse,  have  no  bearing  on  the  rule.  Though,  in  many  cases, 
the  touch  is  insufficient,  until  two  or  three  months  have  elapsed  after 
conception,  to  convince  us  either  that  pregnancy  does  or  does  not 
exist,  it  is,  nevertheless,  the  surest  means  of  exploration  in  our  power. 
It  not  only  serves  to  determine  whether  gestation  exists,  but  it  fur- 
ther indicates  the  degree,  the  kind  ;  it  alone  can  teach  us  whether 
labour  is  near  at  hand  or  begun,  whether  it  is  in  an  advanced  stage, 
whether  the  child  presents  aright,  whether  the  assistance^  of  art  is 
useless  or  necessary,  whether  every  thing  is  right  after  labour,  &c. 
The  touch  then  is  the  principal  lever,  or  at  least  one  of  the  most 
powerful  resources  of  tokologic  science.  But,  in  order  to  practise 
it  with  success,  to  avoid  the  gross  mistakes  that  it  may  cause  us  to 
commit,  to  derive  from  it  every  possible  advantage,  it  is  necessary 
to  practise  it  for  a  long  time,  inasmuch  as  practice  alone  can  make 
us  skilful  in  such  an  operation. 

317.  Position  of  the  woman.  When  the  woman  is  affected  with 
ascites,  hydrothorax,  asthma,  organic  disease  of  the  heart  or  great 
vessels,  when  her  breathing  is  difficult,  she  should  stand  up  during 
the  operation  of  the  touch,  so  as  to  avoid  the  fatigue  and  even  dan- 
ger that  might  be  incurred  by  placing  her  in  a  horizontal  posture. 
If  on  the  other  hand  she  is  weak,  threatened  with  syncope,  hemor- 
rhage, or  convulsions  ;  if  the  womb  is  strongly  inclined  forwards,  or 
if  from  any  other  cause  the  neck  is  thrown  very  far  backwards,  it  is 
better  for  her  to  lie  down.  Finally,  if  any  difficulty  be  experienced, 
she  should  be  examined  in  both  positions,  alternately. 

318.  The  muscles  must  first  be  placed  in  a  state  of  relaxation; 
If  the  woman  is  lying  down,  she  should  be  told  to  bend  her  legs 
and  thighs,  as  well  as  her  head  and  breast,  which  are  to  be  gently 
raised  with  pillows  or  bolsters.  In  the  contrary  case,  she  is  to  be 
placed  against  a  wall,  a  piece  of  furniture,  or  any  solid  body  for  her 
support ;  she  then  separates  and  slightly  bends  her  lower  limbs, 
while  she  at  the  same  time  inclines  her  head  and  breast  a  little  for- 
wards. To  prevent  the  awkwardness  of  such  a  posture,  she  may  be 
permitted  to  rest  her  elbows  or  hands  upon  the  arms  of  some  other 
person,  or  simply  upon  the  edge  of  a  fable,  or  on  a  couple  of  chairs 
placed  expressly  for  that  purpose  on  each  side  of  her. 

319.  Before  we  begin  the  operation,  the  finger  should  be  covered 
with  mucilage  of  flaxseed,  or  marshmallow  root,  olive  or  almond  oil, 
butter,  hog's  lard,  cerate,  white  of  eggs,  or  any  kind  of  grease. 
Mucilage  is  the  best ;  but  when  it  is  not  at  hand,  it  little  matters 
what  substance  we  have  recourse  to,  provided  it  be  unctuous^  and 
not  irritating. 

Q 


122  OF  TRUE  PREGNANCY. 

320.  There  are  two  reasons  for  making  use  of  grease  in  this  way: 
it  would  not  be  so  easy  without  this  precaution  to  penetrate  into  the 
vagina  ;  the  labia,  and  the  hairs  that  cover  them,  might  be  pulled,  and 
thus  be  to  some  women  very  painful ;  if  the  accoucheur  should  hap- 
pen to  have  any  excoriation  upon  his  finger  he  would  by  this  means 
be  less  exposed  to  conta*act  syphilis,  the  itch,  or  other  contagious 
disease  with  which  the  woman  might  be  affected. 

We  should  learn  to  touch  as  readily  with  the  left  hand  as  with 
the  right. 

32 1 .  Supposing  that  two  fingers  can  appreciate  the  physical  cha- 
racters of  a  body  better  than  one.  Stein  recommends  the  introduc- 
tion of  the  fore  and  middle  finger  together  :  some  of  that  writer's 
countrymen  have  followed  his  advice  ;  but  with  the  exception  of  a 
few  very  rare  cases,  it  is  never  conformed  to  in  France.  ,  The  sen- 
sation felt,  instead  of  being  clearer  with  two  fingers,  is  on  the  con- 
trary more  confused,  and  the  index  when  employed  singly  very  cer- 
tainly penetrates  much  farther  than  ifthemedius  is  introduced  along 
with  it. 

322.  In  the  first  place,  in  order  to  introduce  it,  it  should  be  held 
straight  and  strongly  abducted  from  the  other  finger  ;  or  these  lat- 
ter are  flexed  so  that  the  thumb  is  placed  in  the  palm  of  the  hand. 
In  common,  either  of  these  two  methods  may  be  employed  indiffef- 
ently,  but  the  former  does  not  suit  for  women  whose  external  or- 
gans of  generation  are  swelled,  sensitive,  inflamed  or  painful;  the 
latter  is  applicable  to  all  cases,  and,  consequently,  I  think  it  prefer- 
able, but  that  does  not  prevent  me  from  using  the  other  mode  some- 
times. 

323.  It  is  never  indispensably  necessary  to  uncover  the  woman  ; 
if  she  be  lying  down,  the  accoucheur  should  place  himself  beside  her 
bed,  and  the  hand  being  put  under  the  bed  clothes,  iS  carried  up  to 
the  vulva,  passing  beneath  the  ham  corresponding  to  the  hand  that 
is  employed  ;  if  she  is  standing  up,  one  knee  should  be  put  to  the 
floor  ;  according  to  some  it  should  be  the  one  that  corresponds  to 
the  hand  that  is  made  use  of;  according  to  others  it  should  be  the 
opposite  one.  The  former  allege  the  advantage  of  having  a  place 
to  rest  the  elbow  on,  and  of  thus  obtaining  more  firmness  and  surety 
in  the  requisite  motions.  For  my  part,  I  think  we  can  touch  very 
well  in  cither  way  ;  however,  I  have  for  a  long  time  past  adopted 
the  latter  mode,  both  in  my  own  practice,  and  in  my  instructions  ; 
I  find  timt  the  arm  is  freer,  that  it  may  be  more  easily  inclined  for- 
wards or  backwards,  raised  or  depressed  ;  that  it  accommodates  it- 
self better  to  the  necessarily  varying  stature  of  women,  to  the  dif- 
ferent degrees  of  pregnancy,  and  height  of  the  womb.  After  all, 
it  is  rather  a  matter  of  choice  than  of  necessity.  '     ^ ' 


OF  TRUE  PREGNANCY.  123 

324.  The  index  finger  arranged  as  before  said,  with  its  radial 
edge  turned  towards  the  arch  of  the  pubis,  is  first  directed  on  to  the 
perineum,  or  posterior  part  of  the  vulva  ;  the  point  of  the  finger  is 
then  drawn  along  forwards  so  as  to  pass  in  between  the  labia,  and 
penetrate  into  the  vagina  in  the  axis  of  the  perineal  strait,  that  is  to 
say,  from  below  upwards,  and  from  before  backwards,  as  if  it  were 
intended  to  reach  the  sacro-vertebral  angle.  Previously  to  search- 
ing for  the  neck,  it  is  proper  to  explore  the  state  of  the  rectum,  of 
the  bas-fond  of  the  bladder,  of  the  longitudinal  columns  of  the  vagina, 
and  the  conformation  of  the  straits  and  excavation  of  the  pelvis : 
after  this  first  stage,  the  os  tincte  is  to  be  examined  ;  the  thickness 
and  length  of  its  lips  whether  relative  or  absolute  should  be  ascertain- 
ed, as  well  as  their  bumps  or  tubercles,  their  depressions  or  slits,  their 
regularity  or  unevenness,  and  the  form  and  direction  of  the  orifice  ; 
we  should  next  endeavour  to  determine  the  length  of  the  neck  as  well 
as  the  size  of  the  womb,  which  must  be  raised  up  so  as  to  learn  its 
weight,  while  its  dimensions  also  may  be  ascertained,  if,  while  the 
finger  touches  it  in  the  vagina,  we  can  also  succeed  in  feeling  and 
pressing  upon  its  fundus  through  the  abdominal  parietes  with  the 
other  hand. 

325.  With  these  precautions,  it  is  often  possible,  after  the  end  of 
the  third  month,  in  a  lean  woman  whose  abdomen  is  pretty  flaccid, 
to  take  hold  of  the  womb  by  its  neck  and  fundus  at  the  same  time  ; 
to  make  it  incline  backwards,  or  to  either  side ;  to  judge  of  its  mo- 
bility, form  and  size  ;  to  measure  very  exactly  its  length  and  weight ; 
to  become  certain  whether  or  not  it  is  in  a  natural  state,  and  whether 
or  not  the  substance  it  contains  is  fluid. 

326.  The  depression  of  the  cervix,  its  gentle  inclination  forwards 
or  backwards,  its  density,  its  length  and  volume,  whether  a  little 
more  or  less  considerable,  exhibit  varieties  too  multiplied,  and  may 
depend  upon  causes  too  diverse  for  us  to  place  much  reliance  upon 
them.  Besides,  to  judge  of  them,  we  should  have  touched  the  same 
woman  once  or  oftener,  before  she  was  suspected  of  being  pregnant, 
and  every  one  knows  that  this  is  a  condition  rarely  met  with. 
Alphonse  Le  Roy,  in  asserting  with  the  decided  tone  that  character- 
ised him,  that  augmented  heat  of  the  cervix  was  sufficient  ground  for 
him  to  afiirm  that  pregnancy  had  taken  place,  has  only  given  an  addi- 
tional proof  of  his  arrogance  and  temerity.  If  conception  does  in- 
crease the  calorification  of  that  part,  indeed,  do  not  all  the  irritative 
affections  produce  the  same  result  ?  Is  not  the  heat  of  the  cervix 
various  in  different  women,  and  even  in  the  same  woman  at  every 
moment  of  the  day,  of  the  week,  or  month,  or  year  ?  Must  it  not 
present  innumerable  shades,  according  to  the  heat  peculiar  to  each 


124  OF  TRUE  PREGNANCY. 

practitioner's  finger,  and  also  according  to  the  necessarily  varying 
temperature  of  the  same  practitioner's  hand  ? 

327.  Hippocrates  and  the  ancient  physiologists  taught  that  the  va- 
ginal orifice  of  the  womb  closes  immediately  after  fecundation,  so  as 
to  prevent  the  escape  of  the  semen;  Mauriceau  and  other  accoucheurs 
have  remarked,  further,  that  the  cervix  becomes  sharper  than  it  was 
in  the  course  of  the  two  months  preceding  fecundation ;  that  it 
assumes  the  form  of  a  cone  with  its  base  turned  upwards.  These 
changes,  it  is  true,  take  place  in  some  women,  but  they  so  often  fail 
in  those  who  have  never  borne  children,  and  are  so  fugacious,  so 
so  difficult  in  common  to  recognize,  so  slightly  marked  after  a  first 
pregnancy,  that  it  is  almost  impossible  to  derive  any  advantage  from 
them.  .  ' 

328.  Stein  affirms  that  in  the.  first  two  months,  the  posterior  lip, 
naturally  the  shortest,  becomes  the  longest,  and  at  length  reaches  the 
same  level  with  the  anterior  one ;  that  the  slit  in  the  os  tinca3  is  trans- 
formed into  an  opening  more  or  less  regularly  rounded  and  circular; 
that  the  pubic  face  of  the  lower  segment  of  the  womb  gives  birth  to 
a  soft  and  more  or  less  projecting  tumour ;  and  that  these  changes 
most  commonly  suffice  to  prove  that  the  woman  is  with  child.  But 
it  is  so  common  to  meet  with  a  circular  form  of  the  lower  orifice  of 
the  womb  in  women  who  are  not  pregnant  and  who  have  borne 
several  children,  and  even  in  young  virgins  to  see  the  posterior  lip 
as  long  or  even  longer  than  the  other,  either  absolutely  or  only  in 
appearance,  that  the  assertions  of  Stein  do  not  really  deserve  a  se- 
rious refutation. 

329.  I  cannot,  however,  refrain  from  mentioning  a  pecuharity 
which  perhaps  imposed  itself  upon  him  as  that  anterior  projection 
which  is  vaguely  treated  of  in  the  French  translation  of  his  work. 
Jt  has  happened  to  me  several  times,  and  I  have  pointed  it  out  to  a 
number  of  my  pupils,  to  find,  in  v/omen  who  had  been  already  touched 
by  a  good  many  persons,  that  the  anterior  lip  was  sensibly  longer 
and  softer  than  at  the  commencement  of  our  practical  sittings ;  ex- 
amining this  lip  with  care,  it  was  then  easy  to  feel  a  real  crepitation, 
and  to  find  that  it  was  swelled,  and  fungus-like  j  but  thi.s  was  a  state 
wholly  foreign  to  gestation,  and  which  was  produced  solely  by  the 
frequently  repeated  touchings  to  which  we  had  subjected  the  woman. 
At  other  times,  we  feel  above  the  vagina,  immediately  in  front  of  the 
anterior  lip,  a  softer,  larger,  more  regular  and  less  elastic  tumour 
which  does  not  crepitate  ;  but  this  projection,  which  I  have  met  with 
at  every  stage  of  pregnancy,  evidently  depends  upon  the  bladder, 
the  bas-fond  of  which  presses  the  corresponding  wall  of  the  vagina 


OF  TRUE  PREGNANCY.  125 

more  or  less  downwards ;  I  should  not  dare  to  affirm,  moreover, 
that  it  does  not  pretty  frequently  exist  independently  of  the  state  of 
gestation. 

330.  Thus,  until  the  second  or  third  month,  the  sensible  signs, 
the  touch  itself  cannot,  any  more  than  the  rational  signs,  give  us  a 
mathematical  certainty  of  the  existence  or  non-existence  of  gestation. 
They  sometimes  permit  us  to  establish  a  diagnosis  that  is  more  or 
less  probable,  but  never  certain  ;  so  that  during  this  period,  the  touch 
is  in  fact  but  a  feeble  resource,  and  women  should  not,  without  strong 
motives,  be  subjected  to  it. 

At  a  later  period,  although  the  practitioner  cannot  affirm  posi- 
tively that  there  is  a  foetus  in  the  womb,  he  can  at  least  be  sure  that 
the  organ  is  considerably  increased  in  size.  Thenceforth  all  that  is 
necessary  is  to  distinguish  real  gestation  from  the  diseases  that  are 
sometimes  confounded  with  it.  Soon  afterwards  we  are  able  to 
perform  the  hallottement^  and  to  perceive  the  spontaneous  move- 
ments of  the  child,  which  are  the  only  phenomena  that  prove  beyond 
question  the  existence  of  pregnancy. 

331.  Ballottement.  In  effecting  what  is  called  ftaZZo/tewzen^,  after 
having  first  placed  the  index  finger  under  the  cervix,  the  summit  of 
the  other  hand  is  to  be  applied  over  the  fundus  of  the  womb,  by 
pressing  it  against  the  belly,  which  is  to  be  carefully  depressed  so  as 
to  push  away  the  bowels  and  fat.  In  this  way  the  womb  is  held  in 
the  most  exact  manner  possible,  by  the  two  extremes  of  its  longitu- 
dinal diameter,  and  now  the  womb  is  to  be  suddenly  pushed  upwards 
with  the  finger  that  is  in  the  vagina,  while  the  hand  on  the  hypogas- 
trium  attends  to  and  judges  of  the  motion  experienced  by  the  ovum. 
The  foetus,  which  is  movable,  free,  and  the  only  solid  substance 
within  the  amniotic  fluid,  strikes  directly  opposite  to  the  point 
that  received  the  impulse.  If  the  hand  that  is  outside  receives  no 
shock,  the  motion  is  to  be  sent  back  to  the  other  one  in  the  vagina. 
Should  the  first  attempt  fail,  it  is  repeated  several  times,  communi- 
cating the  impulse  with  each  hand  alternately,  and  taking  all  proper 
precautions  not  to  give  the  woman  any  pain.  The  same  thing  hap- 
pens here  that  is  seen  in  physics  when  experiments  are  made  on  the 
transmission  of  motion.  Indeed,  let  a  vessel  full  of  water  be  struck 
on  any  part  of  its  circumference,  and  the  little  figures  that  have  been 
suspended  in  it  by  means  of  glass  bubbles  or  small  bits  of  cork  will 
immediately  move  to  the  opposite  side.  But  it  is  easy  to  understand, 
that  in  order  to  obtain  this  result,  the  foetus  must  have  attained  to  a 
certain  size,  that  there  must  be  a  sufficient  quantity  of  liquor  amnii, 
that  the  uterus  and  parietes  of  the  abdomen  must  not  be  too  thick. 


X26  OF  TRUE  PREGNANCY. 

and  that  the  operation  must  be  done  with  a  dexterity  and  skill  that 
can  only  be  acquired  by  practice  on  the  natural  subject. 

332.  Whenever  a  solid  and  movable  body  has  struck  one  or  both 
hands  during  the  operation  for  ballottement,  there  can  be  no  further 
doubt  as  to  the  woman's  being  pregnant ;  but  care  should  be  taken  not 
to  be  imposed  upon  by  the  jar  of  a  fluid,  or  any  other  kind  of  motion. 
It  is  only  from  the  fourth  to  the  sixth  month  that  the  hallottement 
presents  a  resource  of  any  importance  ;  for  it  is  rarely  that  the  jar 
of  the  foetus  can  be  perceived  before  the  end  of  the  third  ;  and  in 
the  next  three  months  of  gestation  it  is  in  general  too  easy  to  deter- 
mine the  state  of  the  woman  to  make  such  a  recourse  needful. 

333.  Motions  of  the  child.  Ballottement  impresses  on  the  ovum 
only  a  passive  motion,  which  is  the  same  whether  the  foetus  is  dead 
or  alive,  and  which  would  be  the  same  were  it  possible  for  a  poly- 
pus or  any  other  solid  and  large  body  to  be  free  and  movable  in  a 
uterus  filled  with  any  kind  of  fluid.  Ballottement  makes  us  know 
that  pregnancy  exists ;  but  active  or  spontaneous  motions  alone  give 
us  the  certainty  that  the  foetus  is  living. 

334.  The  child  does  not  move  in  an  active  manner  until  after  its 
muscular  system  has  acquired  a  certain  degree  of  development ;  and 
still  its  motions  must  be  so  weak,  that  the  woman  can  hardly  per- 
ceive them  until  in  the  course  of  the  fourth  month.  At  the  begin- 
ning she  has  a  feeling  of  formication ;  after  which  they  acquire  a  force 
that  varies  according  to  the  vigour  of  the  child,  the  stage  of  preg- 
nancy and  the  good  or  bad  health  of  the  mother.  Their  strength 
most  commonly  increases  until  the  birth  ;  sometimes  they  increase 
for  one  or  two  months,  become  less  marked  in  the  sixth  and  seventh, 
and  resume  their  activity  towards  the  end  of  pregnancy.  M.  De- 
sormeaux  has  seen  them  cease  entirely  from  the  end  of  the  fifth 
month,  and  the  child  nevertheless  be  born  strong  and  healthy  at  full 
term  ;  in  other  instances  they  are  never  perceived  at  all :  some  able 
practitioners,  such  as  Mauriceau,  De  la  Motte,  Baudelocquc,  &c. 
mention  women  in  whom  attempts  had  in  vain  been  made  to  excite 
them,  and  who  were  nevertheless  delivered  of  robust  and  well  grown 
children.  It  may  be  supposed  that  plethora,  some  constraint,  some 
difficulty  in  the  circulation  of  the  fluids  of  the  ovum,  or  even  those  of 
the  woman  herself  may  render  them  duller,  slower,  more  obscure  and 
vague  ;  and  that  the  free  exercise  of  all  the  functions,  cheerfulness 
and  contentment  of  the  mother,  and  a  proper  degree  of  strength  on 
the  part  of  the  child  give  them  more  energy  and  vivacity.  Deli- 
cate, nervous,  and  irritable  women  feel  them  sooner  and  plainer 
than  those  whose  sensibility  is  less  exquisite,  who  arc  not  in  the 


'  OF  TRUE  PREGNANCY.  127 

habit  of  carefully  analyzing  their  sensations,  and  who,  in  consequence 
of  their  temperament  or  disposition  being  naturally  more  quiet,  pos- 
sess a  calmer  imagination  and  less  impressible  organs :  the  former 
sometimes  assert  that  they  have  felt  the  child  move  at  the  end  of  the 
third  month,  (which  seems  almost  impossible,  since  the  muscles  are 
still  mostly  gelatinous,)  while  the  latter  do  not  commonly  speak  of 
it  until  towards  the  end  of  the  fourth. 

If  the  motions  of  the  child  are  very  decided,  quick,  and  frequent, 
it  is  not  necessary  for  them  to  move  the  abdominal  parietes  in  an 
evident  manner,  as  is  sometimes  seen,  to  guard  the  woman  against 
confounding  them  in  any  way  with  motions  of  another  kind ;  but 
when  they  are  weak  and  return  but  rarely,  nothing  is  more  common 
than  for  other  sensations  wholly  independent  of  them  to  be  mistaken 
for  them  j  so  that  the  prudent  accoucheur  should  never  pronounce 
upon  them  without  having  made  himself  perfectly  sure, 

335.  For  this  purpose  it  often  suffices  to  apply  the  hand,  which 
must  be  cold  and  naked,  to  the  abdomen  :  it  m*ay  be  previously  rub- 
bed with  brandy,  Cologne  water,  &c.  or  dipped  in  cold  water,  with 
vinegar  and  ammoniac  in  it.  This  application  produces  a  sudden 
transition  in  the  temperature  of  the  hypogastrium,  which  re-acts  upon 
the  child  and  causes  it  to  move  in  a  convulsive  manner.  If  this 
simple  means  does  not  succeed,  the  palm  of  the  hand  is  to  be  placed 
on  one  side  of  the  abdomen,  which  should  then  be  properly  struck 
with  the  other,  as  in  examining  into  the  existence  of  ascites.  The 
foetus  thus  disturbed  scarcely  ever  fails  to  move  with  some  force : 
and  this  is  a  sort  o(  ballottement,  which  possesses  the  advantage  over 
the  common  method  of  not  requiring  the  finger  to  be  introduced  into 
the  sexual  organs,  but  which  has  also  the  disadvantage  that  it  cannot 
be  usefully  employed  until  after  the  fifth  month. 

Auscultation.  After  having  properly  performed  the  touch,  having 
attempted  to  efiect  the  ballottement^  and  to  feel  the  motions,  whether 
active  or  passive,  of  the  foetus  in  vain,  we  have  no  method  of  solving 
the  problem  left  except  auscultation. 

336.  After  Laennec  had  shown  that  it  is  possible  to  see  with  the 
ear  what  is  passing  inside  of  the  chest,  it  was  natural  to  suppose 
that  auscultation  would  soon  be  applied  to  the  investigation  of  the 
diseases  or  functional  changes  of  other  parts  of  the  body.  MM. 
Major  and  Fodere  had  already  given  some  hints  on  the  subject 
when  Mr  Kergaradec,  in  an  interesting  memoir,  maintained,  that 
gestation  may  be  ascertained  with  great  certainty  by  means  of  the 
stethoscope.  According  to  that  physician,  two  kinds  of  sounds  may 
be  heard  in  the  womb  of  a  pregnant  woman  :  one,  which  although 
quicker  and  shorter,  is  analogous  to  that  of  a  feeble  respiration,  is  the 


128  OF  TRUE  PREGNANCY. 

bruit  de  souffle  which  he  has  denominated  the  placental  sound ;  the 
other,  similar  to  the  ticking  of  a  watch  wrapped  up  in  cloths,  de- 
pends on  the  beating  of  the  heart,  and  may  be  called  the  sound 
of  the  heart.  The  former  is  isochronous  with  the  pulsations  of  the 
mother,  which  hinders  it  from  being  confounded  with  the  respira- 
tory sounds  ;  but  it  is  in  almost  every  respect  similar  to  that  caused 
by  muscular  contractions,  that  heard  in  the  large  arterial  trunks 
when  spasmodically  contracted  or  compressed  by  some  external 
tumour,  and  in  the  heart  itself  in  certain  pathological  states  at  pre- 
sent not  well  understood ;  so  that  some  well  performed  experiments 
are  still  necessary  in  order  to  demonstrate  that  it  appertains  to  preg- 
nancy rather  than  to  some  other  condition  of  the  female.  M.  Ker- 
garadec  thought  that  it  corresponded  to  the  place  where  the  placenta 
is  attached,  and  was  produced  by  the  passage  of  blood  from  the  womb 
to  the  vessels  of  the  ovum,  or  in  other  words  by  the  uterine  or  pla- 
cental circulation  ;  but  although  some  facts  seem  to  support  this 
explanation,  there  are  many  others  opposed  to  it,  and  my  own  ob- 
servations lead  me  to  regard  them  as  but  very  improbable  conjec- 
tures. In  the  majority  of  cases,  it  requires  a  very  practised  ear  to 
perceive  them  at  all,  and  this  is  doubtless  the  reason  which  has  in- 
duced many  physicians  to  reject  them  altogether. 

337.  I  have  myself  in  vain  sought  for  it  in  a  great  many  subjects; 
on  the  other  hand  I  have  distinctly  heard  it  in  a  great  many  others. 
It  was  sufficiently  strong  in  three  women  who  were  confined  at  the 
Hospital  de  Perfectionftement^  and  in  two  others  who  were  made  use 
of  for  the  practical  demonstrations  of  my  course,  for  the  least  skilful 
medical  students  and  female  pupils  in  midwifery  to  hear  it  very  plain- 
ly. I  have  never  met  with  it  except  in  the  second  half  of  pregnancy. 
If  Laenncc  and  M.  De  Lens,  who  say  that  they  have  heard  it  before 
the  end  of  the  third  month,  were  not  mistaken,  that  alone  appears  ' 
to  me  to  be  reason  enough  why  it  is  impossible  to  attribute  it  to  the 
placento-uterine  circulation. 

338.  It  should  be  sought  for  between  the  anterior  edge  of  the 
pelvis  and  the  navel,  and  lower  down  in  proportion  as  the  pregnancy 
is  less  advanced. 

339.  The  double-beat,  or  sound  of  the  heart  cannot  be  confounded 
with  any  other  ;  for  the  pulsations  can  be  counted  to  the  number  of  a 
hundred  to  a  hundred  and  forty  or  a  hundred  and  fifty  per  minute, 
while  the  mother's  pulse  beats  only  from  sixty  to  seventy-five  in  the 
same  space  of  time  :  growing  stronger  as  the  fcctus  grows  older, 
this  sound  can  scarcely  be  appreciable  before  the  fourth  month  ;  of 
a  necessarily  variable  intensity,  on  account  of  a  great  many  circum- 
stances that  are  difficult  to  characterize,  it  is  never  hisard  better 


OF  TRUE  PREGNANCY.  129 

than  when  the  child's  back  corresponds  to  some  part  of  the  anterior 
surface  of  the  uterus  ;  I  have  scarcely  ever  failed  to  detect  it  when 
able  to  seek  for  it  with  all  suitable  care  ;  the  anterior  curve  of  the 
foetus,  and  the  relations  of  the  heart  to  the  spine,  are  the  reasons 
why  the  back  is  the  only  part  that  is  evidently  capable  of  transmit- 
ting the  double  beat  to  the  ear  of  the  observer.  From  this  remark 
it  may  be  conceived  that  they  may  change  their  place  if  the  foetus 
changes  its  position,  and  that  before  affirming  that  they  do  not  exist 
at  all,  we  should  have  by  turns  explored  the  hypogastrium  and  the 
loins,  the  flanks,  and  all  the  various  parts  of  the  circumference  of 
the  pelvis. 

340.  In  order  to  perform  the  auscultation,  the  woman  must  be 
lying  down,  although  in  fact  she  might  be  allowed  to  stand  up  ;  if 
the  pregnancy  be  somewhat  advanced  the  ear  will  suffice,  and  some- 
times succeeds  better  than  the  stethoscope  with  persons  not  in  the 
habit  of  using  that  instrument.  However,  it  can  only  be  conveniently 
applied  on  the  anterior  half  of  the  abdomen.  Moreover,  the  friction 
of  the  gown  or  any  other  part  of  the  woman's  dress,  whom  it  is  un- 
necessary to  uncover  during  the  operation,  may  frequently  deceive  us 
as  to  the  nature  of  the  sounds  we  hear.  The  stethoscope  in  gene- 
ral yields  a  clearer  or  more  intense  sound  ;  besides,  it  can  be  applied 
at  all  stages  of  pregnancy,  and  to  all  the  points  to  which  the  foetus 
seems  able  to  turn  its  back :  the  end  piece  is  to  be  taken  off;  then 
after  having  felt  for  the  womb,  it  is  placed  first  on  the  left,  then  on 
the  right,  and  next  on  the  middle  of  the  hypogastrium  5  it  is  even 
applied  to  the  loins,  the  posterior  face  of  the  sacrum,  the  cristas  of 
the  ilia,  the  front  of  the  pubis,  &lc. 

34 1 .  Were  it  always  possible,  the  child's  back,  the  corresponding 
parietes  of  the  womb  and  abdomen,  the  stethoscope  and  the  ear  of 
the  accoucheur  should  not  be  separated  by  any  void  space  and  by  no 
other  part,  and  they  should  constitute  as  it  were  a  continuous  body, 
without  any  interruption  whatever. 

342.  The  sound  of  the  heart  is  a  certain  sign  both  of  pregnancy 
and  ofthe  child's  being  alive  ;  its  strength,  in  general,  indicates  the 
vigour  and  good  health  of  the  child  ;  during  labour,  when  accidents 
occur,  or  when  a  serious  operation  appears  to  be  indispensable,  its 
simultaneous  existence  at  two  opposite  sides  of  the  abdomen  will 
render  it  certain  that  the  womb  contains  two  children  ;  if  met  with 
in  a  woman  whose  uterus  is  but  little  developed,  no  doubt  remains 
of  there  being  an  extra  uterine  pregnancy  ;  but  its  absence,  like  that 
of  the  active  or  passive  motions  of  the  foetus,  does  not  afford  a  con- 
clusive proof  that  there  is  no  gestation,  or  that  the  child  is  not  living. 

343.  As  to  the  bruit  de  soujle,  its  nature  is  still  too  little  under- 
R 


130  OF  TRUE  PREGNANCY. 

stood  to  enable  a  circumspect  practitioner,  at  present,  to  pronounce 
from  its  single  testimony  that  such  or  such  a  woman  is  or  is  not 
pregnant. 

343.  To  determine  the  stage  of  'pregnancy.  After  having  by 
means  of  the  simple  touch,  of  hallottement.,  of  muscular  movements, 
or  of  auscultation,  ascertained  that  there  is  pregnancy,  it  is  still  fur- 
ther useful,  sometimes,  to  determine  its  stage  ;  on  this  subject  I  shall 
not  repeat  what  has  already  been  said  concerning  the  changes  ef- 
fected every  month  in  the  state  of  the  cervix,  the  body  and  fundus  of 
the  womb  ;  I  shall  content  myself  with  remarking  that,  in  order  to 
obtain  a  just  idea  of  these  changes,  especially  those  of  the  neck,  it  is 
often  needful  to  touch  in  a  different  manner  from  that  in  which  it  is 
commonly  done.  In  the  first  place  we  are  not  to  understand  by 
the  necJe  that  portion  merely  of  the  womb  that  projects  into  the 
vagina,  but  rather  all  the  cylindrical  portion  of  the  summit  of  the 
uterine  ovoid,  a  kind  of  appendix  which  cannot  be  completely  felt 
except  by  pushing  back  the  vaginal  cul  de  sac  with  the  finger,  in  the 
centre  of  which  is  felt  the  os  tineas;  in  the  second  place,  in  women 
who  have  had  children,  we  should  make  an  allowance  for  the  thick- 
ness of  its  lips  ;  lastly,  when  the  uterus  is  oblique  in  front,  and  the 
pelvis  not  very  large,  the  orifice  may  be  so  high  up,  that  in  order  to 
reach  it,  the  radial  side  of  the  finger  must  be  turned  backwards,  or 
the  peiineum  somewhat  depressed,  while  with  the  other  hand  ap- 
plied upon  the  epigastrium,  the  fundus  of  the  wOmb  is  thrust  back- 
Wards  towards  the  vertebral  column.  In  other  cases,  particularly 
where  the  superior  strait  is  very  ample,  the  neck  looks  directly  to- 
wards the  anterior  surface  of  the  sacrum ;  to  touch  here,  we  arc 
obliged  to  carry  the  finger  almost  horizontally  backwards,  and  then 
to  bend  it  forwards  in  the  shape  of  a  hook ;  in  other  women  we  meet 
in  the^^uperior  half  of  the  excavation,  a  rounded  tumour,  in  the  pos- . 
terior  part  of  which  the  neck  appears  to  be  obliquely  hollowed  out, 
like  the  ureters  in  the  parieles  of  the  bladder:  with  all  these  precau- 
tions, a  skilful  accoucheur  can  say,  what  is,  within  from  fifteen  to 
thirty  days,  the  period  of  pregnancy  ;  but  it  would  be  dangerous  to 
forget  Ihat  there  are  numberless  causes  of  error,  and  that  we  should 
never,  before  a  court,  give  a  decisive  opinion  until  we  have  j)revi- 
ously  acquired  a  mathematical  certainly  of  the  fact  concerning 
which  we  have  to  pronounce. 

344.  Compound  pregnancy .  It  was  natural  to  suppose  that  the 
uterus  would  bo  larger  when  containing  two  or  more  children,  than 
when  it  encloses  only  a  single  one.  Hence  also  almost  all  those 
appearances  that  depend  upon  the  pressure  upon  and  displacement 
of  the  soft  parts  both  of  the  pelvis  and  abdomen,  have  been  cnumc- 


OF  TRUE  PREGNANCY.  131 

rj^ted  among  the  symptoms  of  compound  pregnancy.  But  all  that 
has  been  said  on  this  subject  throws  but  a  vague  light  upon  the  ques- 
tion ;  varices,  infiltration,  cedema,  swellings,  difficulty  in  moving  the 
lower  limbs,  engorgement  of  the  labia  pudendi,  dyspepsia,  difficulty 
in  making  water,  in  walking,  breathing,  digesting ;  an  elliptical  or 
flattened  shape  of  the  bag  of  waters  ;  weakness  of  the  uterine  con- 
tractions ;  lypothymia  and  syncope  ;  the  belly  being  larger,  rounder, 
rather  depressed  than  salient  along  its  median  line  ;  motions  or  ihe 
fcetus  felt  with  more  force  and  frequency,  and  on  both  sides  of  the 
abdomen  at  once,  &c.  all  fail,  too  frequently  in  twin  pregnancies,  for 
us  to  place  much  confidence  in  them:  besides,  all  these  signs  are  rarely 
met  with  together,  and  a  majority  of  them  may  be  met  with  where 
there  is  only  a  single  fcetus  in  the  womb  ;  which,  further,  may  be 
easily  imagined  to  be  the  case,  inasmuch  as  the  size  of  the  gestative 
organ  may  be  much  larger  in  some  cases  of  simple  pregnancy  than 
in  others  where  the  gestation  is  evidently  double  or  triple. 

345.  Baudelocque  teaches  that  the  touch  is  able  to  conduct  us  to 
more  satisfactory  results.  He  says,  for  example,  that  where  the  belly 
is  very  large,  if  there  be  only  one  fcetus,  the  ballottement  will  be 
very  easy ;  while  if  there  be  two  of  them,  there  will,  on  the  contrary, 
be  some  difficulty  in  effecting  it,  and  that  their  motions  or  their 
most  projecting  portions  can  be  distinctly  felt,  through  the  parietes 
of  the  abdomen,  in  several  places  at  the  same  time.  It  may  be  added 
that  we  ought  to  be  able  by  means  of  auscultation  to  hear  the  sound 
of  the  heart  at  two  places,  at  some  distance  from  each  other,  and 
that  if  the  pulsations  denominated  ^placental  are  of  any  use  in'obste- 
trics,  they  will  also  be  heard  at  two  distinct  points. 

346.  The  union  of  these  signs  would 'give  us,  without  the  least 
doubt,  a  certainty  of  the  woman's  being  pregnant  with  two  or  more 
children ;  but  the  want  of  them  is  far  from  always  constituting  a 
negative  sign  of  compound  pregnancy.  M.  Desormeaux  cites  a 
case  wherein  the  most  manifest  ballottement  coincided  with  a  very 
gyeat  size  of  the  abdomen,  and  in  which  that  able  accoucheur  could  • 
only  detect  a  single  fcetus,  while  the  ovum  in  fact  contained  two. 
On  the  other  hand,  the  ear  cannot  detect  the  cardiac  pulsations  of 
two  foetuses,  when  they  are  so  situated  that  one  is  above  or  in  front 
of  the  other,  so  that  it  is  most  commonly  impossible,  previously  to 
delivery,  to  affirm  whether  the  pregnancy  is  simple  or  double. 


132  OF  TRUE  PREGNANCY. 


^I^HEf     Of 


SECTION  2. 
Of  Extra-uterine  Pregnancy. 


§.  I.  Of  ovarian  pregnancy. 

347.  Andry,  and  the  animalculists,  who,  like  him,  supposed  that 
the  living  corpuscles  of  the  seed  passed  along  the  Fallopian  tubes  in 
order  to  join  the  ovule  in  the  female  seminal  gland,  did  not  attempt 
to  contest  the  existence  of  ovarian  pregnancy,  and  among  modern 
practitioners  there  are  few  who  think  of  calling  it  in  question ;  Boer- 
haave  even  thought  he  could  divide  it  into  external  and  internal,  but 
this  question  appears  to  me  to  have  been  too  lightly  judged,  and  to 
deserve  a  new  examination. 

348.  In  whatsoever  manner,  indeed,  fecundation  is  really  effected, 
whether  by  means  of  an  aura,  an  animalcule,  or  by  any  other  prin- 
ciple of  the  semen,  it  must  happen  that  the  germs  of  the  two  sexes 
shall  come  in  contact  with  each  other;  this  contact  cannot  take 
place  without  a  rupture  of  the  covering  of  the  ovary,  and  of  the 
capsule  of  the  ovule ;  so  that  by  the  simple  admission  that  an  ovule 
is  vivified,  it  can  no  longer  be  said  to  be  enclosed  in  the  ovary,  un- 
less wc  believe  with  Chaussier,  that  the  male  germ  reaches  that  of  the 
female  by  means  of  absorption.  A  great  many  cases  of  ovarian  preg- 
nancy arc  to  be  found  in  the  various  scientific  collections :  an  infinity 
of  physicians  and  accoucheurs  of  merit  Jiave  stated  that  they  -have  met 
with  them  in  practice  ;  but  it  is  easy,  upon  a  moment's  reflection,  to 
perceive  that  not  one  of  the  cases  hitherto  published,  not  even  those 
of  Littre  and  Smith,  prove  undeniably  that  ovarian  pregnancy  has 
ever  been  seen.  It  is  so  easy  in  the  dead  body  to  confound  this 
kind  with  abdominal  pregnancy,  those  who  have  treated  of  them  have 
given  so  few  details,  pathological  anatomy  was  at  that  period  so  little 
cultivated,  that  no  result  can  in  fact  be  obtained  from  the  observa- 
tions of  the  authors  ;  and  while  the  moderns  shall  not  have  demon- 
strated, with  the  scalpel,  that  tlie  ovum  is  sometimes  really  situated 
in  the  ovary  and  not  in  the  adjacent  parts,  reason  dictates  to  us  that 
we  should  not  admit  the  existence  of  ovarian  pregnancy. 

349.  T  have  learned  at  my  own  expense  how  easy  it  is  to  be  im- 
posed upon  in  this  matter.  In  1.324  and  1025  I  met  with  the  re- 
mains of  extra-uterine  conceptions  in  four  different  subjects  ;  I  re- 
moved the  sexual  parts  with  great  care,  and  thought  I  was  in  pos- 
session of  four  facta  in  proof  of  the  existence  of  ovarian  gestation. 
I  presented  them  to  the  !:>ociele  Philomathiqve,  where  several  mem- 
bers expressed  doubts  us  to  the  possibility  of  the  fact.  MM.  Blain- 
ville  and  Sj^rres  w«!ro  good  enough  to  assist  at  the  dis.section,  which 


OF  TRUE  PREGNANCY.  I33 

[  performed  the  next  day.  We  satisfied  ourselves  that  three  of  these 
tumours  were  outside  of  the  germiferous  gland  ;  we  experienced 
greater  difficulty  in  regard  to  the  fourth,  which  did  not  exceed  an 
inch  in  size ;  but  at  length,  after  having  completely  isolated  the  Fal- 
lopian tube,  we  found  that  the  detritus  of  the  conception  was  con- 
tained in  a  special  sac  between  the  peritoneal  coat  and  the  proper 
covering  of  the  ovary,  which  was  wholly  distinct  from  it.  Certainly, 
none  of  the  facts  that  have  been  cited  as  proofs  of  the  existence  of 
ovarian  pregnancy  have  been  more  carefully  examined  ;  and  certes, 
if  it  had  not  been  for  the  objections  and  the  presence  of  an  able  de- 
fender of  the  opposite  opinion,  we  should  have  remained  convinced 
that  the  seat  of  the  tumour  was  in  the  very  parenchyma  of  the  ovary. 

§.  II.  Abdominal  pregnancy  (peritoneal^  ventose,  external,  (^c"). 

350.  Admitting  that  fecundation  is  effected  in  the  ovary,  it  is  very 
natural  that  the  vivified  ovule  should  sometimes  fall. into  the  belly 
■  instead  of  being  engaged  in  the  Fallopian  tube  ;  in  reflecting  upon 
the  anatomical  arrangement  of  the  parts,  one  is  disposed  to  believe 
that  such  accidents  are  not  uncommon  ;  if,  says  Bianchi,  it  does  not 
occur  more  frequently,  it  is  doubtless  because  a  very  great  majority 
of  the  germs  that  escape  in  this  way  die  before  they  become  attached 
to  the  serous  membrane  that  receives  them.  However,  some  mo- 
dern accoucheurs  have  asserted  that  it  could  not  occur ;  that  the  pe- 
ritoneum is  not  sufliciently  vascular  to  supply  to  the  germ  the  requi- 
site means  of  development ;  that  in  the  instances  in  which  dissection 
had  shown  the  foetus  and  its  secundines  to  be  in  the  abdomen,  there 
had  been  previously  a  tubal  or  uterine  pregnancy.  It  is  true  tliat  the 
tube  and  the  ovary  are  commonly,  and  sometimes  a  part  of  the  uterus 
itself  is,  lost  as  it  were  in  the  mass  of  the  tumour,  and  that  it  would 
be  imprudent  in  that  case  to  affirm  that  the  ovum  was  not  originally 
located  in  another  place ;  but  it  is  at  the  same  time  an  incontro- 
vertible fact  that  in  many  of  the  published  cases,  both  the  ovary  and 
the  tube  retained  their  natural  condition,  and  were  completely  foreign 
to  the  sac  which  contained  the  foetus.  On  the  other  hand,  the  vete- 
rinary physicians,  more  competent  even  than  accoucheurs  to  solve 
this  problem,  have  completely  embraced  the  affirmative,  relying  on 
numerous  and  authentic  facts  that  have  been  noted  for  thirty  years 
past :  besides,  the  difference  between  the  structure  of  the  peritoneum 
and  that  of  the  womb  cannot  in  fact  serve  as  a  basis  for  any  good 
argument ;  the  ovum,  which  may  be  compared  to  the  bud  of  a  plant 
endowed  with  life  that  is  still  very  obscure,  is  so  constituted  as  to 
unite  with  the  first  living  part  whereon  nature  places  it.  The  in- 
terior of  the  womb  or  of  the  tube  doubtless  suits  it  better ;  but  are 


154  O^  TRUE  PREGNANCY. 

we  allowed  on  that  account  to  say  that  it  can  never  take  root  in  any 
other  situation  ?  Therefore  nothing  in  the  laws  of  the  organism  for- 
bids us  to  admit  the  possibility  of  a  peritoneal  pregnancy  ;  and  I 
should  not  have  taken  the  trouble  to  combat  the  opposite  opinion, 
were  it  not  that  M.  Dubois  still  maintains  it,  and  throws  around  it 
all  the  weight  of  his  imposing  authority. 

351.  The  fecundated  vesicle,  soon  covered  with  a  velvety  pile 
similar  to  the  spongioles  of  the  roots  of  plants,  must  rapidly  contract 
adhesions  with  the  surfaces  on  which  it  rests ;  there  is  an  afflux  of 
fluids  to  that  point,  appearances  similar  to  those  of  a  local  and  very 
circumscribed  inflammation  soon  occur,  and  an  accidental  sac  is 
soon  organized  around  the  little  ovum,  which  is,  so  to  speak,  thence- 
forth protected  against  the  action  of  the  surrounding  organs. 

§  III.  Of  tubal  pregnancy. 

352.  Tubal  pregnancy,  more  common  than  any  of  ^the  others, 
and  the  only  one  that  has  not  been  contested  by  the  partizans  of ' 
ovarian  fecundation,  could  only  be  rejected  by  authors  who  believe 
that  vivification  takes  place  in  the  womb ;  but  the  cases  on  record 
are  now  so  numerous  that  it  is  no  longer  permissible  to  entertain 
the  slightest  doubt  in  relation  to  it.  Without  mentioning  those  that 
are  detailed  in  the  works  of  Bartholin,  of  Riolan,  of  Bianchi  and 
others;  in  the  dissertations  of  MM.  Bry,  de  Bouillon,  Bonis;  of  those 
related  in  the  Revue  Medicale ( 1 826),  the  Nuovo  Giorn.  dei  Lett.  Ital. 
(1825),  of  another  reported  by  M.  Vallerand,  Nouv.  Bibl.  Med. 
(1826),  and  of  an  infinitude  of  others  that  have  been  published  in  the 
French  and  Foreign  Scientific  Collections,  I  will  state  that  in  1816 
I  saw  in  the  body  of  a  woman  who  died  at  the  hospital  of  Tours,  a 
very  perfect  ovum  in  the  second  month  of  its  growth,  which  was 
very  completely  enclosed  in  the  outer  half  of  the  Fallopian  tube, 
of  which  the  root,  the  fimbriated  extremity,  the  canal,  and  all  the 
other  parts  were  still  easy  to  be  recognized.  Any  one  may  see,  in 
the  Museum  of  the  Ecole  de  Mcdccine,  a  wax  model  which  mathe- 
matically demonstrates  the  samp  thing.  We  may  conceive,  further, 
that  in  this  species  of  pregnancy,  the  product  of  fecundation  may 
attach  itself  to  any  portion  of  the  length  of  the  tube,  but  that  it  will 
most  frccjucntly  stop  in  the  trumpet  part  of  it,  and  that  after  a  cer- 
tain lapse  of  time  it  must  be  difticult  to  decide,  at  a  glance,  whether 
the  pregnancy  is  tubal,  rather  than  abdominal  or  ovarian.  It  may 
besides  be  conceived,  that  the  uterine  duct,  soon  distended,  and 
thinned,  might  burst,  and  transform  a  tubal  into  a  peritoneal  preg- 
nancy; so  that  the  latter  may,  in  fact,  be  either  primitive  or  essen- 
tial, or  else  secondary  or  accidental ;   but  it  is  superfluous,  with 


OF  TRUE  PREGNANCY.  135 

Boehmcr,  to  describe  both  an  internal  and  an  external  tubal  preg- 
nancy. 

§.  IV.  Of  interstitial  pregnancy. 

353.  The  ancients  made  no  mention  of  what  M.  Mayer  has  pro- 
posed to  denominate  interstitial  pregnancy.  Noticed  by  Schmidt, 
Albers,  Hederich,  Cams,  MM.  CHet,  Bellemain  and  Lartet,  Dance 
and  Moulin,  it  had  been  studied  with  some  care  by  MM.  Mayer  and 
Meckel  in  Germany  ;  but  scarcely  any  thing  had  been  said  on  the 
subject  when  M.  Breschet,  to  whom  MM.  Bellemain  and  Lartet 
had  abandoned  the  Specimen  which  had  served  as  the  basis  of  their 
observation,  undertook  to  collect  all  the  known  facts  in  relation  to 
the  topic. 

The  ovum  in  this  case  does  not  lodge  betwixt  the  peritoneum  or 
the  mucous  coat  and  the  proper  tissue  of  the  womb  ;  but  in  the  very 
substance  of  the  fleshy  structure.  In  five  out  of  seven  cases,  it  has 
been  found  on  the  left  side,  above,  behind,  before,  or  below  the 
tube,  which  did  not  in  any  case,  as  we  are  assured,  communicate 
with  the  cavity  which  contained  the  production.  It  is  at  least  cer- 
tain, that  in  the  one  I  had  an  opportunity  of  examining  along  with 
M.  Breschet,  there  was  no  communication  between  the  natural 
cavity  of  the  genital  organs  and  the  preternatural  sac  which  con- 
tained the  foetus.  M.  Meniere  has  published  in  the  Archives  Gene- 
rales  de  Medecine  some  very  judicious  reflections  on  interstitial  preg- 
nancy; but  the  case  he  had  in  connexion  with  M.  Dujardin  does 
not  appear  to  me  to  belong  to  that  class.  Dionis,  Canestrini, 
Einsenman  and  Ramsbothara,  have  each  related  a  case  which  seems 
to  be  more  like  it. 

Attempts  have  hitherto  been  vainly  made  to  explain  the  mechanism 
of  this  kind  of  pregnancy ;  M.  Breschet  has  supposed  that  when  the 
ovule  is  about  to  enter  the  uterus,  it  might,  upon  meeting  with  some 
obstacle,  engage  in  the  open  orifice  of  some  one  of  the  venous 
sinuses  that  open  at  the  origin  of  the  Fallopian  tubes,  and  thus 
gradually  insinuate  itself  into  the  very  substance  of  the  parietes  of 
the  womb.  But  as  these  orifices  have  no  existence  in  fact,  the  ex- 
planation falls  to  the  ground  of  itself.  On  the  other  hand,  admitting 
that  the  angles  of  the  uterus,  at  birth,  being  very  long,  bear  a  partial' 
resemblance  to  the  horns  of  the  womb  or  the  ad  uterum  of  quad- 
rupeds, M.  Brechet  presumes  that  the  narrow  passage  which  then 
leads  to  the  seminiferous  tube,  might,  by  becoming  obliterated,  com- 
pel the  germ  to  deviate  from  its  ordinary  route.  But  if  be  true  that 
such  a  conformation  is  sometimes  met  with,  I  can  at  least  aflirm 
that  it  is  rarely  so,  and  is  not  according  to  the  natural  order  of 


136  OF  TRUE  PREGNANCY. 

things.  This,  therefore,  is  also  but  a  gratuitous  hypothesis.  The 
same  must  be  true  of  the  passage  discovered  by  M.  Baudelocque, 
Jun.  in  the  side  of  the  womb,  as  well  as  of  the  preternatural  cavities 
mentioned  by  Morgagni,  Valsalva,  «Sfc.  It  is  true  we  may  have 
recourse  to  anatomical  varieties,  to  diseases,  anomalies,  to  deviations 
of  all  sorts,  and  indulge  in  a  thousand  suppositions ;  but  the  wisest 
course  is  to  confess,  frankly,  that  the  mechanism  of  interstitial  preg- 
nancy is  wholly  unknown. 

§.  V.  Causes  of  extra-uterine  pregnancy. 

354.  The  density,  the  preternatural  thickness  of  the  covering  of 
the  ovule,  or  envelopes  of  the  ovary,  too  strong  an  adhesion  of  the 
germ,  its  being  situated  too  deep  or  too  near  the  ligament  of  thej 
ovary,  the  obliteration,  paralysis,  spasm,  bad  direction,  excessive  ot^ 
insufficient  length,  engorgement,  or  antiperistaltic  motion  of  thSj 
Fallopian  tube,  inflammation  and  ulceration  of  its  mucous  membrane, 
induration  of  its  trumpet  end,  or  of  one  or  more  of  its  fringes,  the 
contraction  of  its  external  orifice,  all  the  changes  and  anomalies  that 
this  canal  may  exhibit,  whether  in  regard  to  its  conformation  or  its 
situation,  a  laceration  of  the  womb,  spoken  of  by  Boehmer,  Bianchi, 
and  Weinckneicht,  may  well  have  produced  some  instances  of  extra- 
uterine pregnancy  ;  but  it  is  certain,  that  in  this  respect  science  is 
possessed  of  scarcely  any  thing  beyond  probabilities.  Astruc  believed 
that  unmarried  women  were  more  liable  to  be  affected  with  this  sort  of 
accident  than  others.  Kruger,  who  unites  in  this  opinion,  supposes 
that  the  ovule  remains  in  the  ovary,  stops  in  the  tube,  or  slips  into  the 
peritoneum,  because  fear,  alarm,  indignation,  by  attacking  women 
suddenly  in  the  midst  of  the  most  lively  enjoyment,  or  shortly  after- 
wards, must  occasion  a  disturbance  in  the  whole  organism,  whose 
effects  reach  even  to  the  sexual  organs.  A  case  by  M.  Lalleraand, 
and  another  by  Baudelocque,  seem  to  lend  some  support  to  the 
opinion  of  Astruc ;  in  fact,  the  extra-uterine  conception  in  the  two 
women  who  were  the  subjects  of  it,  seemed  to  have  been  effected, 
at  the  very  instant  of  a  violent  fright,  occasioned  in  one  by  the  re- 
membrance of  some  piece  of  forgetfulness,  and  in  the  other  by  a 
sudden  noise,  which  made  her  afraid  of  being  caught  in  Jlagrante 
delicto ;  but  as  nothing  similar  has  been  noticed  in  other  cases,  this 
explanation  can  only  be  regarded  as  a  tolerably  plausible  hypothesis. 

365.  Those  who  insist  that  fecundation  is  eflcctcd  in  the  womb, 
necessarily  reject  all  these  modes  of  viewing  it,  and  can  give  no 
account  of  extra-uterine  pregnancy,  but  by  supposing  a  retrograde 
movement,  by  means  of  wliich  the  ovule  returns  from  the  uterus  into 
the  tube,  &,c.   The  assertions  of  Planchon,  who  affirms  that  the  tubes 


OF  TRUE  PREGNANCY.  137 

are  slightly  dilated  in  the  first  weeks  of  conception,  a  remarkably 
curious  case  reported  by  Palune,  in  whicli  it  is  said  that  the  umbili- 
cal cord  of  a  foetus  enclosed  in  the  fimbriated  extremity  was  insert- 
ed into  a  globose  placenta,  situated  in  the  very  cavity  of  the  womb, 
are  very  rare  facts,  and  ought  to  be  met  with  anew  before  tliey  can 
give  much  weight  to  such  conjectures. 

§.  VI.  Signs  and  terminations  of  preternatural  pregnancy. 

356.  The  continuance  of  the  menses,  severe  pains  in  the  hypo- 
gastrium,  nausea,  and  frequent  vomiting,  as  well  as  severj^  other 
distressing  symptoms,  considered  as  signs  of  extra-uterine  pregnancy, 
sometimes  indeed  do  accompany  it ;  but  as  they  also  are  oftener 
wanting,  and  not  at  all  uncommon  in  .natural  pregnancy,  their  pre- 
sence is,  on  that  account  alone,  of  very  little  weight.  Though  the 
breasts  undergo  no  change,  secrete  no  milky  fluid  ;  though  the  belly 
is  uneven,  its  growth  more  rapid,  and  its  development  chiefly  on  one 
side ;  though  the  motions  of  the  foetus  are  earlier  felt,  and  through 
surfaces  apparently  very  thin  ;  though  the  womb  remains  quite  small, 
in  some  cases  of  extra-uterine  pregnancy,  the  contrary  happens  in  a 
still  greater  number  of  cases,  and  one  or  more  of  these  irregularities 
is  frequently  met  with  even  in  simple  pregnancy. 

However,  though  it  is  true  that  the  womb  sometimes  increases  in 
size  in  such  cases,  it  is  equally  true  that  the  changes  which  it  then 
experiences  are  rarely  sufficiently  marked  to  make  us  believe  in  the 
existence  of  a  natural  pregnancy  of  four  or  five  months  standing. 
If,  therefore,  the  abdominal  tumour  lias  risen  early  above  the  mar- 
ginal strait,  and  is  found  in  one  of  the  iliac  fossae  ;  if  it  appears  to  be 
full  of  bumps,  varicose,  and  if  pulsations  can  be  felt  in  it ;  if  it  be 
easy  to  feel  the  protuberances  and  motions  of  the  foetus,  while  the 
parietes  of  the  abdomen  preserve  nearly  theirnatural  thickness,  and, 
on  the  other  hand,  we  can  ascertain  by  the  touch  that  the  weight 
and  size  of  the  womb  are  not  at  all,  or  but  slightly  increased  ;  that 
the  cervix  has  not  to  any  sensible  degree  diminished  in  length,  al- 
though it  has  altered  in  respect  to  its  position,  direction,  density,  and 
even  form,  then  it  is  evident  that  the  pregnancy  is  preternatural. 

357.  However,  it  may  be  conceived,  that  if  the  ovum  has  fixed  itself 
to  some  part  in  the  pelvis,  or  to  some  point  on  the  periphery  of  the 
womb  ;  that  if  it  has  been  arrested  very  near  the  root  of  one  of  the 
tubes,  or  even  in  the  substance  of  the  parietes  of  the  uterus,  all  these 
signs  may  in  fact  not  exist,  and  the  preternatural  pregnancy  be  con- 
founded with  an  ordinary  gestation.  In  these  cases  the  uterus  swells, 
softens,  undergoes  a  major  part  of  the  changes  that  characterize  real 

S 


138  OF  TRUE  PREGNANCY. 

pregnancy,  its  cavity  becomes  filled  with  a  concrescible  matter  which 
is  amorphous,  a  kind  of  membrana  caduca  or  anhistous  layer,  ob- 
served by  Bertrandj,  Chaussier  and  others  ;  the  form  of  the  belly  and 
the  motions  >)f  the  fcetus  exhibit  nothing  peculiar,  and  ballotteraent 
itself  is  not  always  impossible. 

358.  In  general,  the  sexual  organs  depart  but  very  little  from 
their  natural  state,  when  the  foetal  cyst  is  not  within  the  tube,  and 
contracts  no  adhesions  with  the  womb.  On  this  subject,  the  case 
noticed  by  M.  de  Bouillon  should  be  regarded  only  as  an  uncommon 
excepti^.  In  these  cases  the  cervix  rarely  becomes  much  short- 
ened, nor  does  its  orifice  dilate  in  any  considerable  degree ; .  it  is 
found  to  be  much  lower  or  higher,  more  forward  or  backward,  or  to 
one  side,  than  the  presumed  period  of  the  pregnancy  would  seem  to 
indicate. 

359.  After  all,  neither  the  rational  nor  sensible  signs  suffice,  until 
the  end  of  the  third  month,  to  prove  that  pregnancy  is  extra-uterine. 
After  this  period,  it  will  in  most  cases  bo  possible,  by  means  of  some 
or  all  of  them,  to  establish  an  almost  certain  diagnosis ;  the  evidence 
derived  from  them  will  at  least  give  rise  to  suspicions  sufficiently 
strong  to  fix  the  attention  of  the  practitioner. 

360.  As  to  the  distinctive  signs  of  the  different  species  of  extra- 
uterine pregnancy,  I  do  not  think  it  would  be  useful  to  treat  of 
them  in  this  place  ;  the  knowledge  of  them  could  not  be  beneficially 
applied ;  besides,  all  those  that  have  been  mentioned  are  too  uncer- 
tain to  deserve  the  least  confidence :  since,  even  on  the  dead  body, 
we  can  scarcely  decide,  even  by  means  of  the  scalpel,  whether  the 
ovum  is  situated  in  the  tube,  the  ovary,  or  the  peritoneum,  it  would 
be  in  some  measure  ridiculous  to  desire  to  obtain  any  certainty  in 
relation  thereto,  on  the  living  subject. 

361.  Extra-uterine  pregnancy  commonly  terminates  before  the  fifth 
month  ;  Baudelocque,  MM.  Arnault,  Novara,  Delisle  and  some 
others  have  nevertheless  seen  it  much  more  prolonged,  and  even  to 
the  term  of  ordinary  gestation.  These  authors,  especially  the  for- 
mer, mention  a  very  remarkable  circumstance ;  it  is  that  in  these 
cases,  at  the  close  of  a  kind  of  labour,  attended  with  intermittent 
pains,  that  are  sometimes  pretty  strong,  a  commencement  of  dilata- 
tion of  the  neck,  a  discharge  of  mucus,  of  a  bloody  ffuid,  and  what 
seems  still  more  surprising,  very  regular  contractions  of  the  womb 
or  of  the  fcjctul  cyst  are  observed  to  take  place.  In  fact  we  may 
conceive  of  a  part  of  these  phenomena  in  tubal  pregnancy  ;  the  tube 
being  composed  of  the  same  elements  as  the  womb,  it  is  quite  na- 
tural for  it  to  enjoy  the  same  properties ;  but,  in  .abdominal  preg- 
nancy, we  can  only  account  for  the  contraction  of  the  cyst  by  sup- 


OF  TRUE  PREGNANCY.  139 

posing  that  there  has  been  a  development  of  fleshy  fibres  in  its 
parietes,  at  the  cost  of  the  elastic  cellular  layer  which  is  enclosed  in 
the  peritoneum  of  the  pelvis. 

362.  Termination.  Interstitial  pregnancy  alone  admits  of  a  pos- 
sibility of  extracting  the  fcEtus  by  the  natural  passages ;  the  caliber 
of  the  tube,  its  slight  dilatability,  do  not  allow  us  even  to  think  of  it 
in  the  other  species  ;  in  this  view,  therefore,  extra-uterine  pregnancy 
is  always  dangerous,  both  for  the  mother  and  child  :  its  natural  ter- 
minations are  the  death  of  the  feetus,  and  rupture  of  the  cyst. 

363.  Death  of  the  foetus.  It  is  rare  for  the  feetus  to  continue 
alive  beyond  the  second  or  third  month  ;  after  its  death,  which  hap- 
pens for  want  of  nutrition,  or  in  consequence  of  inflammation  of  its 
envelopes,  it  sometimes  happens  that  the  liquor  amnii  as  well  as  all 
the  other  fluid  portions  of  the  ovum  are  absorbed,  the  child  hardens, 
petrifies,  or  is  transformed  into  gras  de  cadavre,  the  cyst  contracts, 
thickens,  and  becomes  fibrous,  fibro-cartilaginous,  or  even  osseous, 
and  the  whole  resolves  itself  into  a  solid  tumour,  which  may  remain 
in  the  abdomen  for  an  indefinite  period,  without  compromitting  the 
life  of  the  woman.  In  other  cases  the  sac  is  transformed  into  a  real 
suppurating  cavity,  the  foetus  is  decomposed,  dissolved,  or  putrefies, 
and  then  the  cyst  soon  contracts  adhesions  with  the  surrounding  parts, 
so  as  speedily  to  open  into  the  bladder,  the  cfecum,  the  colon,  the 
small  intestines,  the  rectum,  or  directly  outwards  through  the  pari- 
etes of  the  belly  or  perineum,  if  not  immediately  into  the  peritoneum. 
Sometimes  the  ovum  becomes  merely  filled  with  a  fluid  which  is 
more  or  less  thick  and  transparent,  of  a  yellow,  brown,  grey,  or  red- 
dish colour,  but  not  purulent ;  or  it  is  converted  intom  cyst,  in  which 
as  much  as  one  hundred  and  fifty  pounds  of  fluid  have  been  found, 
and  containing  the  debris  of  a  foetus:  an  instance  of  which  is  report- 
ed by  Vassal. 

The  first  case  is  the  most  fortunate  of  all ;  with  it  should  be  class- 
ed most  of  those  pretended  pregnancies  that  have  been  said  to  last 
two,  four,  ten,  fifteen,  twenty,  thirty,  and  even  forty  years :  the 
second  is  always  accompanied  or  followed  by  serious  symptoms  ; 
inflammation  is  propagated  to  the  circumjacent  parts,  gives  rise  to 
violent  fever,  and  sooner  or  later  brings  on  a  fatal  termination  ;  the 
patient  most  commonly  becomes  hectic,  for  she  is  exhausted  by  an 
abundant  suppuration  ;  sometimes,  also,  all  the  parts  of  the  foetus 
escape  one  after  another  ;  the  sac  is  gradually  Emptied,  becomes 
clean,  and  contracts  ;  the  suppuration  ceases  by  degrees,  and  the 
wound  at  last  closes,  or  at  least  is  reduced  to  the  state  of  a  fistulous 
ulcer,  which  is  rather  more  troublesome  than  dangerous. 

364.  Every  species  of  extra-uterine  pregnancy  may  terminate  by 


140  OF  TRUE  PREGNANCY. 

the  laceration  of  the  ovum,  and  of  the  sac  which  serves  in  place  of  a 
womb  ;  examples  of  this  kind,  if  we  may  credit  M.  Mesniere,  have 
been  noticed  both  in  interstitial  and  abdominal  pregnancy  ;  but  tubal 
pregnancy  most  frequently  terminates  in  this  way  :  although  very 
extensible,  the  parietes  of  the  tube  are,  nevertheless,  too  thin  to  ad- 
mit of  the  enlargement  of  the  cyst  beyond  the  third  or  fourth  month. 
In  some  instances  the  rupture  occurs  suddenly,  and  seems  to  be 
occasioned  by  some  exertion,  or  fall,  &c.;  sometimes,  on  the  other 
hand,  it  is  effected  and  prepared  for  by  slow  degrees,  by  the  mecha- 
nical thinning,  the  softening,  or  some  other  change  of  a  portion  of 
the  fcEtal  sac.  In  all  cases  where  no  conservative  adliesions  have 
been  formed,  the  water  of  the  amnios,  the  foetus,  and  the  blood  that 
flows  from  the  lacerated  surfaces,  pass  into  the  cavity  of  the  perito- 
neum ;  lipothymia,  syncope,  convulsions  incessantly  repeated,  and 
intolerable  pains,  often  carry  off  the  sufferer  in  a  few  hours  ;  in  other 
instances  vital  resistance  does  not  so  readily  yield  ;  a  violent  perito- 
nitis comes  on,  and  death  succeeds  on  the  second,  third,  or  fourth 
day.  Finally,  in  some  rare  cases,  nature,  with  proper  assistance, 
resists  the  first  dangers  of  this  redoubtable  tempest,  and  a  protracted 
inflapimation  permits  the  effused  matters  to  accumulate  in  a  more 
circumscribed  space,  and  give  birth  to  a  real  abscess,  which  may 
still  leave  some  chance  of  saving  the  patient. 

365.  Treatment.  The  impossibility  of  certainly  recognising  the 
nature  of  extra-uterine  pregnancy  in  the  first  months  of  its  existence, 
is  the  reason  why  attempts  to  remedy  it  are  scarcely  ever  made  un- 
til the  occurrence  of  symptoms,  announcing  the  death  of  the  fcetus 
or  rupture  of  its.coverings  :  besides,  the  powers  of  art  are  so  limit- 
ed in  these  circumstances,  that  the  only  assistance  which  it  is  pos- 
sible to  afford  would  be  almost  as  dangerous,  in  itself  consider- 
ed, as  the  natural  terminations  of  the  affection.  Gastrotomy,  the 
only  remedy  that  has  been  proposed,  can  boast  of  no  successes  as 
yet;  in  one  case,  published  by  M.  De  Bouillon,  the  woman  sur- 
vived eighteen  days  ;  nature,  on  the  contrary,  when  left  to  her  own 
resource,  has  several  times  succeeded  in  triumphing  over  all  obsta- 
cles. Nevertheless,  the  fears  of  Levret  and  Sabattier,  in  regard  to 
hemorrhage,  suppuration,  and  wounds  of  the  peritoneum,  are  evi- 
dently exaggerated  ;  it  would  seem,  a  priori^  that  gastrotomy  ought 
to  be  much  less  frequently  fatal  tlian  is  commonly  supposed. 

366.  On  the  otiior  hand,  although  wc  have  no  right  to  invoke  past 
experience  in  its  favour,  we  should  not  forget  that,  having  been 
hitherto  performed  in  despair  of  all  other  assistance,  we  have  no 
reason  to  be  surprised  at  its  not  having  prevented  death  from  taking 
place.     I  think,  therefore,  with  M.  Desormeaux,  that  if  recourae 


OF  TRUE  PREGNANCY.  141 

were  had  to  it  early,  before  the  formidable  array  of  inflammatory 
symptoms  have  developed  themselves,  before  peritonitis  becomes  of 
itself  mortal,  a  considerable  number  of  women  might  be  saved.  It 
has  been  maintained  that  in  all  cases  it  should  not  be  had  recourse 
to  until  the  seventli  month  of  pregnancy,  unless  it  be  certain  that  the 
fa3tus  is  dead,  and  the  cyst  opened  into  the  peritoneum  ;  that  other- " 
wise,  we  should,  without  advantage  to  the  mother,  sacrifice  the  life  of 
a  child  which  we  might  possibly  have  conducted  to  its  full  term,  and 
rescued  alive.  This  reasoning  is  good  for  nothing  ;  the  chances  of 
success  in  the  operation  are  so  much  the  more  numerous  in  propor- 
tion as  the  pregnancy  is  less  advanced  ;  in  this  case  there  is  too  lit- 
tle probability  of  the  future  life  of  fhe  foetus,  for  it  to  be  balanced 
against  that  of  the  mother.  After  seven  months,  when  the  child  is 
viable*,  reason  and  humanity  both  dictate  its  performance  without 
hesitation.  Even  although  the  accoucheur  should  not  arrive  until 
after  the  rupture  of  the  cyst,  he  should  still  instantly  open  the  parie- 
tes  of  the  abdomen  :  with  the  operation  death  is  but  too  probable, 
but  without  it,  it  is  nearly  certain. 

367.  In  cases  where  gastrotomy  is  not  applicable,  we  must  be 
content  to  prescribe  for  symptoms,  to  moderate  the  violence  of  in- 
flammation, to  prevent  as  far  as  possible  the  formation  of  pus,  to  fa- 
vour the  production  of  adhesions,  so  as  to  circumscribe  the  effusion, 
to  sustain,  or  also  to  diminish  the  strength  by  means  of  regimen  or 
blood-letting,  according  as  the  appearances  of  reaction  or  exhaustion 
may  seem  to  require  ;  we  must  assist  in  the  escape  of  those  portions 
of  tlie  ovum  which  present  themselves  in  the  vagina,  the  bladder, 
the  rectum  ;  if  abscesses  form,  they  must  be  opened  ;  and  we  must 
prevent  the  stagnation  of  pus  or  of  any  matters  in  a  state  of  decom- 
position ;  in  one  word,  we  should  put  under  contribution,  one  after 
another,  accordingly  as  they  may  be  indicated,  baths,  injections, 
enemata,  a  severe  diet,  an  analeptic  regimen,  general  or  local  bleed- 
ing, and  rest  or  exercise. 

*  I  have  left  this  word  untranslated :  it  expresses  that  state  of  development  in 
which  a  child  may  live,  when  Independent  of  its  connexion  with  the  mother.  I 
trust  the  reader  will  pardon  me  for  introducing  it  here,  especially  as  it  is  getting 
fast  into  use  among  the  profession  in  this  city. — Tr. 


142  OF  FALSE  PREGNANCY. 


ARTICLE  II. 


Of  False  Pregnancy. 

368.  Numberless  cases  prove  that  various  diseases  may  give  rise 
to  a  belief  in  the  existence  of  pregnancy  in  women  who  are  not 
gravid,  and  vice  versa.  A  woman  of  the  Fauxbourg  Saint  Marceau 
was  with  child,  says  M.  Desormeaux  ;  certain  impudent  quacks 
plunged  a  trocar  into  her  abdomen, *and  she  died  in  a  iew  hovers  af- 
terwards !  I  was  called,  in  consultation,  to  a  lady,  in  order  to  de- 
cide whether  it  was  necessary  to  perform  the  cassarian  operation  ; 
the  patient  was  affected  with  peritonitis  of  which  she  recovered,  and 
a  scirrhous  ovarium  of  which  she  died  !  It  is  useless  to  invoke  the 
rules  of  art  against  errors  so  gross  ;  but  there  are  cases  so  obscure 
that  the  most  skilful  practitioner  may  really  mistake  their  true  na- 
ture. M.  Lefebvre,  in  his  thesis,  has  shown  that  even  animals 
pretty  frequently  exhibit  similar  anomalies. 

369.  Retention  of  the  menses,  ascites,  or  encysted  di'opsy,  tym- 
panitis, polypi,  scirrhus,  cancers  of  the  womb,  tumours  in  the  ovaria, 
the  tubes  or  the  pelvis,  and  other  lesions  besides,  often  produce  a 
major  part  of  the  rational  signs,  and  even  some  of  the  sensible  signs 
of  pregnancy.  However,  one  must  be  very  inattentive  or  inexpe- 
rienced, not  to  avoid  mistakes  in  almost  all  these  cases. 

370.  Who  can  confound  the  symptoms  of  scirrhus  of  the  cervix 
and  ulcers  of  the  uterus  with  the  phenomena  of  gestation,  after  hav- 
ing touched  the  woman  ?  Is  not  the  presence  of  a  polypus  most 
commonly  accompanied  with  hemorrhage  1  Does  it  ever  admit  of 
ballottement,  or  make  us  believe  we  feel  the  spontaneous  motions  of 
a  foutus  ?  Do  the  progress  of  the  affections,  the  state  of  the  cer- 
vix, &LC.  in  any  case  resemble  those  of  natural  pregnancy  ? 

371.  The  accumulation  of  blood,  serum,  or  gas  in  the  womb 
might  indeed  impose  upon  us  in  this  matter.  On  this  subject  we 
may  refer  to  the  memoir  lately  published  by  Madame  Boivin.  But 
if  the  womb  is  filled  with  blood,  or  if  the  person  has  always  had  dif- 
ficult menstruation,  the  touch  shows  that  the  hymen  is  imperforate, 
that  the  vagina  or  some  other  part  of  the  genital  organs  are  not 
properly  formed  ;  if  it  bo  a  married  woman,  or  one  whose  menses 
had  been  previously  regular,  there  will,  in  general,  be  found  at  the 
same  time  more  or  less  numerous  indications  of  disease,  which  clear 
up  the  diagnosis  ;  besides,  the  motions  of  the  fcetus  are  never  met 
with  in  those  cases. 


OF  FALSE  PREGNANCY.  I43 

372.  In  the  case  oi  hydrometra  we  are  in  possession  of  the  same 
resources,  and  the  local  affection  is  accompanied  with  so  serious  a 
change  in  the  general  health,  that  with  a  little  reflection  error  be- 
comes from  that  very  circumstance  almost  impossible. 

373.  In  uterine  tympanitis  the  womb  may  acquire  a  considerable 
size,  but  it  always  remains  very  light,  there  is  no  ballottement^  and 
percussion  of  the  belly  occasions  such  a  resonance  as  at  once  dis- 
sipates all  uncertainty. 

374.  Encysted  dropsy,  fibrous  or  scirrhous  tumours,  any  unna- 
tural growth  in  the  ovary  or  parts  connected  with  the  womb,  might, 
at  most,  be  confounded  with  extra-uterine  pregnancy,  inasmuch  as 
the  neck  in  those  cases  undergoes  only  very  slight  changes ;  the 
want  also  of  the  positive  signs  of  the  presence  of  a  child,  the  general 
state  and  progress  of  the  affections  will  always  suffice  to  prevent  us 
from  asserting  that  there  is  one,  and  frequently  to  lead  us  to  main- 
tain that  there  is  no  gestation  in  the  case. 

373.  As  to  ascites,  peritoneal  tympanitis,  effusions  of  pus  or  blood 
in  the  abdomen,  encephaloid,  fibrous,  scrofulous,  steatomatous,  or 
any  other  kind  of  tumours,  and  the  various  lesions  of  organs  contain- 
ed in  the  belly,  they  are  so  many  diseases  or  symptoms  of  diseases, 
which  only  resemble  pregnancy  in  the  distention  of  the  abdomen 
they  occasion,  and  a  few  other  still  more  inconclusive  signs.  If  the 
peritoneum  is  distended  with  gas,  percussion  will  show  it  at  once  to 
be  so :  in  ascites  the  fluid,  falling  to  the  lowest  places,  according 
to  the  laws  of  gravity,  will  give  to  the  belly  a  form  too  readily  dis- 
tinguishable from  that  of  pregnancy  for  those  two  states  to  be  con- 
founded, and  the  difference  is  still  greater  in  all  the  other  afliections 
that  I  have  just  now  mentioned. 

376.  The  group  of  symptoms,  known  as  nervous  or  hysterical 
pregnancy,  have  most  frequently  been  the  cause  of  error  on  this 
head.  It  is  most  frequently  met  with  about  the  period  of  cessation 
of  the  cataraenia,  or  in  unmarried  women  of  an  irritable  or  nervous 
habit,  in  such  as  having  lost  their  first  children,  are  much  tormented 
with  a  desire  of  having  more,  those  who  have  remained  several  years 
in  a  state  of  widowhood,  and  think  they  have  been  fecundated  by  a 
second  husband.  The  menses  are  suppressed,  nausea,  qualms, 
changes  in  the  breasts,  in  the  digestion,  and  sometimes  all  the  ra- 
tional signs  of  pregnancy  supervene,  and  now  and  then  the  woman 
goes  so  far  as  to  affirm  that  she  feels  the  motions  of  the  child  quite 
strong  :  and  what  is  more,  there  have  been  skilful  accoucheurs  who 
have  partaken  of  the  error.  According  to  M.  Orfila,  professor  Du- 
bois was  not  afraid  to  confess  that  he  had  himself  been  deceived. 

377.  A  lady,  thirty-eight  years  of  age,  who  had  had  no  children 


r 


144  OF  FALSE  PREGNANCY, 

for  twelve  years,  and  who  would  have  given  the  world  to  become  a 
mother  by  the  man  with  whom  she  was  associated,  sent  for  me  in 
1823  to  prevent  an  abortion  with  which  she  thought  herself  threat- 
ened. According  to  her  account,  she  was  four  months  gone  with 
child  ;  the  size  of  her  abdomen,  and  numerous  sympathetic  pheno- 
mena seemed  to  confirm  her  assertions  ;  she  had  felt  the  motion, 
and  the  slight  discharge  of  blood  that  alarmed  her  had  been  provoked 
by  violent  exercise.  After  two  or  three  days  her  fears  were  quieted; 
but  they  recurred  again  two  months  later.  New  hopes  again  suc- 
ceeded. The  period  so  ardently  desired  arrived  at  last;  labour 
pains  came  on  ;  a  skilful  midwife  repaired  to  the  woman,  who,  was 
overwhelmed  with  joy  :  three  days  passed  away  in  pretty  severe  suf- 
fering without  appearing  to  advance  the  period  of  delivery  ;  I  was 
called  upon:  I  examined  her,  and  found  the  cervix  as  well  as  the  body 
of  the  womb  in  a  natural  state.  I  pronounced  her  to  be  not  preg- 
nant; she  became  enraged  ;  I  was  dimissed,  and  learned  four  days 
afterwards  that  her  belly  had  fallen,  tiiat  nothing  had  passed  out 
from  the  sexual  organs,  and  that  the  woman's  health  was  restored. 

378.  Here,  as  in  all  analogous  cases,  the  examination  of  the  organ 
of  gestation  would  have  sufliced  after  the  fifth  month  to  destroy  the 
illusion  ;  but  the  patient  cherished  her  error  so  dearly,  that  she  would 
not  permit  herself  to  be  examined,  and  more  particularly  as  she  en- 
tertained not  the  shadow  of  a  doubt  as  to  her  condition. 

I  do  not  here  treat  of  molar  pregnancy,  nor  hydatid  pregnancy, 
because  moles  and  hydatids  of  the  womb  being  nothing  but  products 
of  unnatural  conception,  give  rise  to  the  same  phenomena  as  natu- 
ral pregnancy,  and  always  end  in  abortion. 


ARTICLE  Ilf. 

Of  Pregnancy,  as  it  regards  the  Sex  of  the  Fcatus. 

§  I.  Is  it  possible  to  ascertain  the  sex  of  the  fa:;lus  during  preg- 
nancy ? 

379.  When  we  reflect  on  the  powerful  and  various  reasons  that 
should  lead  man  to  seek  in  the  future  for  what  may  subserve  or  dis- 
turb his  interests  and  his  passions,  the  desire  of  knowing  the  sex  of  a 
child  still  inclosed  in  tiie  vvNjmb  of  its  mother  surely  seems  to  be  quite 
legitimate.  The  woman  wlio  becomes  pregnant  rarely  fails  to  attach 
an  idea  of  greater  happiness  to  one  sex  than  to  the  other.  In  the  most 
common  conditions  of  social  life  the  husband  himself  is  often  tor- 


SEX  OF  THE  FCETUS.  145 

mented  with  the  same  inquietudes.  If  to  this  sentiment  which  is  so 
general  be  added  the  fears  of  a  whole  family  threatened  with  extinc- 
tion for  want  of  heirs  male ;  the  alarm  of  a  whole  people ;  the  various 
clashing  designs  of  all  nations  united  by  the  bonds  of  civilization 
■  when  the  reigning  dynasty  of  a  great  empire  has  no  hope  save  in 
the  being  who  is  as  yet  unborn,  we  shall  comprehend  the  efforts 
that  have  in  all  past  time  been  made  to  satisfy  public  curiosity  on 
this  head. 

380.  The  gods,  diviners,  and  sorcerers,  have  in  turn  been  con- 
sulted :  at  Rome,  Livia  had  patience  enough,  assisted  by  her  women, 
to  complete  the  incubation  of  an  egg  with  the  warmth  of  her  hands  ; 
being  persuaded  that  if  a  male  was  hatched  from  this  egg,  the  child 
with  which  she  was  pregnant  would  be  a  boy,  and  that  the  reign  of 
Augustus  might  thus  be  continued.  The  Egyptians  and  Indians 
depended  on  the  state  of  the  heavens,  or  on  the  nature  of  the  con- 
stellations, at  the  moment  of  fecundation ;  the  Greeks  and  all  the 
people  of  the  ancient  world  used  to  rely  upon  the  phases  of  the 
moon,  &c.  But  unfortunately  not  one  of  these  auspices  but  has 
deceived  the  credulity  of  poor  man. 

381.  Founding  on  the  debatable  principle  that  the  male  embryo 
is  sooner  developed  than  the  female,  Aristotle  pretends,  as  well  as 
Hippocrates  and  many  other  ancient  authors,  that  the  woman 
quickens  earlier  with  a  boy  and  later  with  a  girl.  Setting  out  with 
the  same  idea,  the  relative  strength  of  the  fcetus  has  been  transferred 
to  the  mother  ;  it  has  been  said  that  she  feels  more  vigour,  activity, 
gaiety,  contentment ;  that  her  eyes  are  more  lively,  her  face  more 
blooming,  her  pulse  larger,  more  frequent,  her  digestion  easier ; 
that  all  her  functions,  in  a  word,  are  executed  more  freely,  when 
she  is  to  bear  a  male  child,  than  when  she  is  pregnant  with  a  female ; 
that  a  brown  or  black  ray  along  the  median  line  of  the  belly,  greater 
strength,  livelier  colour,  nipples  more  prominent,  a  harder  and 
tenser  breast,  stronger  pulsation  of  the  carotids,  veins  larger  on  the 
right  than  on  the  left  side,  announce  the  presence  of  a  boy  ;  that  in 
getting  up  or  walking  the  woman  advances  the  right  knee  or  foot 
first ;  that  the  womb  is  inclined  to  the  right,  that  the  urine  is  con- 
stantly loaded,  that  it  deposits  a  lateritious  sediment,  if  there  be  a 
male  child  ;  and  that  opposite  phenomena  are  observed  when  it  is 
of  the  female  sex. 

382.  1  do  not  think  it  needful  to  combat  in  a  serious  way  the 
reasons  by  which  physiologists  and  physicians  have  supported  these 
assertions  ;  I  should  not  have  deemed  it  worth  while  even  to  mention 
them,  if  they  had  not  given  rise  to  a  crowd  of  prejudices  that  are 
spread  among  the  vulgar,  prejudices  whidh  the  quacks  make  the 

T 


146  SEX  OF  THE  FCETUS. 

most  of,  and  which  the  ablest  accoucheur  is  sometimes  compelled 
to  manage  as  well  as  he  can,  when  unable  wholly  to  destroy  them. 
I  shall  content  myself  with  observing  that  the  several  phenomena 
I  have  just  now  enumerated  have  been,  and  continue  to  be  met  with 
every  day,  as  much,  and  not  more  for  one  sex  than  for  the  other ;  that 
vvhat  passes  as  indicating  a  boy,  Osiander,  relying  upon  calculations, 
asserts  that  he  has  most  frequently  observed  in  women  who  brought 
forth  only  girls,  and  that  none  of  the  numerous  signs,  established 
a  priori,  upon  false  notions,  have  ever  been  confirmed  by  the  care- 
ful observation  of  facts.  All  that  can  be  said  in  this  regard  is,  that 
certain  women,  when  they  are  pregnant  with  a  boy,  feel  certain 
symptoms,  so  distinct  from  those  they  experience  when  carrying  a 
female,  that  they  can  scarcely  be  deceived ;  but  then  the  signs  attri- 
buted to  pregnancy  with  the  male  sex  sometimes  announce  the  pre- 
sence of  a  female  foetus,  and  vice  versa ;  most  frequently  there  is  a 
blending  of  the  phenomena  proper  to  the  two  opposite  sexes,  which 
always  return  with  the  same  character  for  the  same  sex  ;  so  that  these 
peculiarities,  entirely  individual,  only  applicable  to  a  few  subjects,  and 
moreover  pretty  rare,  can  be  of  no  use  except  to  those  women  alone 
who  are  affected  with  them. 

383.  The  old  women  say  that  if  the  first  conception  takes  place 
during  the  waxing  of  the  moon  it  will  produce  a  boy,  but  if  in  the 
wane  the  woman  will  on  the  contrary  be  delivered  of  a  girl ;  others 
equally  skilful  admit  that  the  child  will  be  of  the  same  sex  with  the 
last  one  the  mother  bore,  provided  the  moon  did  not  change  within 
three  days  after  that  confinement ;  finally,  some  accoucheurs,  freely 
trusting  to  chance,  ascertain  first  what  the  family  or  the  lady  most 
desire,  and  very  good  naturedly  promise  what  is  wanted.  It  is  best 
in  my  opinion  to  pursue  just  the  contrary  course  :  if  a  girl  is  wanted, 
promise  a  boy,  and  vice  versa.  The  reason  of  this  is,  that  if  you 
are  deceived,  the  woman,  happy  to  have  the  sex  she  longed  for, 
readily  forgives  your  mistake,  and  is  satisfied  to  laugh  at  your  pre- 
tended skill.  If  it  turns  out  as  you  promised,  on  the  other  hand, 
the  parents  are  compelled  in  spite  of  their  disappointment  to  pro- 
claim your  cleverness. 

384.  Here  is,  besides,  another  unfailing  method :  as  our  ances- 
tors performed  so  many  miracles  with  the  moon,  we  may  also  make 
a  small  trial  of  the  power  of  this  wonderful  planet.  If  obliged  to  de- 
clare the  sex  of  the  fatus  before  its  birth,  wc  may  content  ourselves 
with  asserting  that  it  will  be  like  the  last  child,  provided  the  moon 
docs  not  change  within  the  first  nine  days  of  the  lying  in,  and  that 
the  contrary  will  happen  in  the  other  event :  now  if  the  event  should 
confirm  the  sentence,  nothing  more  is  wanting  ;  but  if  on  the  con- 


SEX  OF  THE  FOETUS.  147 

trary  it  should  be  of  the  sex  that  was  not  expected,  all  we  have  to 
do  is  to  go  back  and  see  that  the  reckoning  had  been  badly  made  ; 
that  if  the  moon  has  not  changed  her  nature,  she  has  at  least  changed 
her  phase,  which  amounts  to  the  same  thing  ;  any  body  may  see  that 
in  this  way  error  cannot  occur,  for  the  Innar  phases  recur  every 
seven  days.  There  is  perhaps  a  little  trickingin  this  course  of  pro- 
ceeding ;  but  provided  no  more  weight  is  given  to  it  than  it  really 
deserves,  we  may,  in  acting  thus,  satisfy  every  body  and  do  no  harm 
to  any  one. 

§.  II.  Is  it  possible  to  procreate  either  sex  at  pleasure  ? 

385.  The  desire  of  knowing  before  hand  the  sex  of  the  fcEtus  has 
given  rise  to  one  of  the  most  piquant  questions  in  physiology.  It 
has  been  asked  whether  man  can  by  means  of  known  influences 
determine  the  production  of  one  sex  rather  than  the  other;  and 
this  point  in  the  science,  which  was  discussed  in  the  time  of  Hippo- 
crates, still  engages  the  attention  of  several  naturalists. 

386.  Relying,  we  scarcely  know  on  what,  unless  it  be  upon 
the  grand  idea  that  the  strongest  side  belongs  to  the  strongest  be- 
ing, the  father  of  medicine  teaches  that  both  in  animals  and  in  the 
human  species,  the  right  testicle  and  the  right  ovary  produce  male 
germs,  while  female  germs  come  from  the  left ;  this  opinion  of  the 
ancients,  without  having  ever  been  generally  adopted,  without  having 
ever  been  fortified  by  a  single  direct  experiment,  has  nevertheless 
passed  down  for  ages,  and  claims  even  in  our  day  some  partisans, 
even  among  learned  physicians.  However,  admitting  the  fact,  one 
great  difficulty  would  still  remain  to  be  got  over  in  applying  it. 
How  shall  the  seminal  matter  of  the  right  gland,  rather  than  that  of 
the  left,  get  into  the  womb,  and  vice  versa  ?  In  quadrupeds  indeed 
it  would  be  possible  to  take  a\<fay  from  one  the  right  and  from  an- 
other the  left  prolific  gland  ;  but  what  man  would  submit  to  such  a 
mutilation  for  the  sake  of  being  able  to  procreate  a  boy  rather  than 
a  girl  ?  Another  expedient  was  evidently  necessary  ;  and  Millot  has 
gravely  advised  the  couple  to  lie,  during  a  fruitful  copulation,  on  the 
side  where  the  germ  of,  the  sex  they  desire  to  have  is  found.  We 
might  to  a  certain  extent  excuse  the  ancients,  who  believed  that  the 
human  uterus  was  two-horned  like  that  of  brutes,  for  entertaining 
such  an  opinion,  for  believing  that  the  semen  of  the  right  ovary 
would  perhaps  stop  in  the  right  horn,  provided  the  two  individuals 
took  the  precaution  of  lying  on  the  corresponding  side  during  the 
coition  ;  but  in  the  nineteenth  century  such  conjectures  are  merely 
subjects  for  ridicule,  and  scarcely  deserve  the  trouble  of  refutation. 

•    387.  Moreover,  it  is  actually  demonstrated  that  the  basis  of  this 


148  SEX  OF  THE  FffiTUS. 

hypothesis  is  entirely  false.  Legallois  caused  rabbits  from  which 
he  had  removed  one  ovary  to  be  covered,  and  found  that  it  did  not 
prevent  them  from  engendering  young  of  different  sexes  ;  as  to  the 
human  species,  without  mentioning  the  cases  of  men  who  having 
lost  one  of  the  genital  glands  have  notwithstanding  procreated  both 
boys  and  girls,  I  will  relate  two  facts  that  are  decisive  on  this  subject. 
A  woman  died  some  years  ago  at  the  Maternite  at  Paris  ;  she  was 
the  mother  of  ten  or  twelve  children  of  both  sexes,  and  neverthe- 
less her  sexual  organs  were  so  disposed,  that  there  was  only  one 
ovary  and  one  tube  attached  to  the  corner  of  a  womb  which  was 
itself  reduced  to  one  of  its  halves.  In  the  case  by  MM.  Jouvet  and 
Gamier,  communicated  to  the  Academy  by  M.  Ollivier  (d'  Angers), 
it  appears  that  the  woman  had  been  confined  five  times ;  that  she 
had  had  four  boys  and  one  girl,  that  the  four  first  pregnancies  seemed 
to  have  been  effected  in  the  left  uterine  sinus,  and  the  fifth  and  last 
only  in  that  on  the  right  side.  Lastly,  all  naturalists  know  that,  in 
animals,  where  the  uterus  is  completely  bi-lobated,  the  same  horn 
is  often  filled  at  the  same  time  with  both  male  and  female  foetuses. 

388.  While  doing  justice  to  these  suppositions  physiologists  have, 
notwithstanding,  retained  a  hope  of  one  day  ascertaining  the  con- 
ditions which  cause  one  sex  to  be  born  rather  than  the  other. 
M.  Bory-de-Saint-Vincent  has  already  emitted  the  bold  opinion, 
that  certain  organic  particles  are  susceptible  of  passing  with  nearly 
the  same  facihty  into  the  vegetable  or  animal  state.  Mr  Edwards 
thinks  he  has  observed  that  the  molecules  of  several  conferva3,  and 
other  beings  of  doubtful  nature,  may  be  at  will  transformed  into  in- 
dividuals of  either  organic  kingdom.  Finally,  there  were  commu- 
nicated, in  1825,  to  the  Societe  Philomatique,  certain  researches 
which  would  tend  to  induce  the  belief  that  by  modifying  in  a  certain 
way  the  influences  under  which  the  fecundation  and  entire  repro- 
duction of  insects  is  effected,  it  is  possible  to  occasion  the  produc- 
tion either  of  males  or  females  at  pleasure. 

389.  The  ancient  agriculturists  were  convinced,  and  country  peo- 
ple still  think,  that  if  the  north  wind  prevails,  that  if  the  season  be 
dry  and  cool  rather  than  warm  and  moist,  when  goats,  sheep  and 
cows  are  admitted  to  the  males,  there  will  be  fewer  females  pro- 
duced, than  under  the  influence  of  a  contrary  state  of  the  atmos- 
phere. They  are  persuaded,  moreover,  that  in  order  to  obtain  a 
larger  proportion  of  males,  there  is  no  better  plan  than  to  cause  the 
females  to  be  covered  by  the  most  vigorous  animal  of  the  kind. 
They  therefore  take  care  to  choose  the  most  active,  the  strongest, 
the  youngest  and  most  robust  buck,  or  ram,  or  bull,  or  stallion  they 
can  find. 


SEX  OF  THE  FCETCFS.  I49 

390.  BeaidoB,  llnae  tnditkms  have  been  lately  subjected  to  the 
test  of  ejqwnoMiit,  and  fiillj  confirmed  by  the  interesting  researches 
of  M.  Giroa  De  Bussaringue.  Numerous  obpervations  have  been 
made  by  Has  pluknthrc^NC  cultivator  on  horaes,  cows,  sbeep,  birds, 
&c  for  seveni  auooeaave  yeais,  and  aoowding  to  aD  appearance, 
with  the  greatea*  care.  Now,  tbey  go  to  show  that  the  stronger 
the  ouJe  at  the  peiiod  (d  fecundation,  the  gieater  is  the  chance  of 
oblMaing  males.  For  instance,  in  a  flock  of  aheem  those  that  are 
first  covered  produce  fewer  males  than  those  that  come  immediately 
after  them,  and  these  many  more  than  the  last  moiety ;  for  tbe  ram 
does  not  appear  to  enjoy  his  whc^  prolific  eneigy  until  after  a  cer- 
tain number  of  copulatiotts,  and  afterwards  he  beoxnes  exhausted, 
gradually  losing  his  atreogth.  ^ 

391.  Other  reasons  still  may  be  cited  in  support  of  those  above 
mentioned ;  pigeons,  doves,  partridges,  and  many  other  birds  that 
unite  in  couples,  daring  each  season  of  Aor  loves,  produce  neariy 
the  same  number  of  males  as  of  faooales.  The  gaUinacee,  the  com- 
mon fowl,  on  the  oontraiy,  wad  geese,  ducks,  tuikeys,  &c  where  tbe 
same  male  suffice  for  several  females,  fiunish  many  more  females 
than  males  of  th^  r^pective  sped^ ;  while  bitches,  cats  and  she 
wohes,  which  ordinarily  permit  the  approaches  of  several  dogs,  &e. 
ei^ender  move  males  than  females.  In  fine,  it  b  supposed  that  where 
poi^any  is  allowed  in  the  horoan  species,  as  in  Persia  and  Turi^ey, 
there  are  more  girls  than  boys  bom,  and  that  in  Europe  where  this 
custom  is  not  tolerated,  the  contrary  is  generally  found  to  be  the 
case,  or  at  least  that  the  proportions  of  the  two  sexes  are  about 
equal. 

Gonseqomtly,  it  becomes  probable  that  the  nature  of  the  sex  b 
determined  by  that  one  of  the  couple  whose  prolific  power,  whether 
absdute  or  relative,  is  greatest  at  the  moaioiit  of  oaooq»tion.  It  b 
true  that  nwneroos  researches  are  yet  necessary,  to  transform  this 
fMoposition  into  a  mathematical  truth ;  but  if  it  should  ever  be  con- 
finned  by  authentic  and  carefol  observation,  it  is  evident  that  the 
act  of  procreating  the  sexes  at  will,  will  no  longer  be  a  chimera, 
and  that  we  ought  not  to  give  up  tbe  hope  of  being  able  to  predict 
to  pregnant  women,  that  tbey  shall  be  defivered  of  a  boy  rather  than 
of  a  gill.  But  it  is  doubtful  whether  by  adoptii^  tbe  course  and 
language  of  M.  Mayer,  we  shall  evw  attain  to  any  thing  satisfactory 
on  this  interastii^  point  (^  physiology. 

§.  III.  Of  the  influence  of  the  seasons  and  of  pabUc  {Mosperity  on 
the  production  of  the  sexes  and  on  the  propmiion  of  conoqitions. 
392.  An  impcHtaqt  inquiry,  and  which  flows  BatnnOy  fiom  the 


150  SEX  OF  THE  F(ETUS. 

preceding,  would  be  to  know,  whether,  in  poor  countries  or  in  years 
of  scarcity,  and  in  provinces  where  the  inhabitants  are  naturally  weak- 
ly, idle  and  wretched,  the  female  sex  exceeds  the  male  in  number  : 
in  order  to  resolve  it,  it  would  be  necessary  to  consult  the  records  of 
the  civil  state  of  people  in  the  most  opposite  conditions ;  this  work, 
which  several  moderns  are  on  the  point  of  undertaking,  has  by 
M.  Bailly  been  already  performed  for  the  city  of  Celles,  from  which 
it  appears  that  the  proportion  of  girls  is  decidedly  larger  than 
that  of  boys,  in  that  barren  and  poor  canton.  However,  M.  Vil- 
lerme,  who  devotes  himself  with  such  praiseworthy  ardour  to  this 
branch  of  statistics,  and  who  has  made  his  observations  on  a  much 
larger  scale,  has  not  come  to  the  same  conclusions  ;  he  has  found 
that,  in  Sologne  and  other  very  poor  departments,  there  are  born 
as  large  a  proportion  of  males  as  in  the  most  opulent  and  agreeably 
situated  cities ;  that  the  miserable  peasants  of  Scotland,  reduced  to 
the  necessity  of  living  on  potatoes  and  beans,  procreate  as  many 
male  children  as  the  rich  inhabitants  of  the  environs  of  London. 

After  all,  though  it  be  right  to  state  that  prosperity  or  misery 
exert  no  marked  influence  on  the  proportion  of  the  sexes,  there  is  no 
reason  why  we  should  be  surprised  at  it ;  for  men  and  women  are 
placed  in  the  same  circumstances.  That  merely  proves  that  abso- 
lute force  is  not  in  this  case  one  of  the  essential  conditions,  but  it 
does  not  in  any  respect  diminish  the  important  bearing  of  the  rela- 
tive force  of  the  couple. 

393.  There  is  no  one  who  has  failed  to  remark  that  births  are 
more  numerous  at  certain  times  and  in  certain  countries,  and  more 
rare  in  others ;  but  no  attempt  had  been  made  to  explain  these  appa- 
rent anomalies,  nor  prove  that  they  were  in  some  degree  fixed  in 
their  recurrences.  M.  Villerme  has  taken  upon  himself  this  double 
care :  in  a  memoir  read  to  the  Academy  of  Sciences,  he  says  that 
out  of  a  total  of  7,G6 1,437  births,  reduced  (ramenees)  to  12,000 ; 
1093  took  place  in  January,  1136  in  February,  1117  in  March, 
1057  in  April,  1000  in  November,  981  in  December,  981  in  Sep- 
tember, 964  in  October,  965  in  May,  927  in  August,  896  in  June, 
and  884  in  July,  and  that,  consequently,  the  relative  frequency  of 
conceptions  is  far  from  being  the  same  at  all  seasons  of  the  year. 

394.  M.  Villerm6,  always  relying  on  calculations,  in  the  same  way 
passes  successively  in  review  the  influence  of  holidays  and  public  re- 
joicings, the  first  periods  of  marriage,  fasts  and  privations,  tempera- 
ture, latitude,  vegetable  or  animal  regimen,  prosperity,  civilization, 
liberty,  the  poverty  and  the  calamities  of  the  population,  on  the  num- 
ber of  fecundations,  and  demonstrates  that  many  more  children  arc 
born  under  a  fine  climate,  in  countries  where  the  arts,  industry, 


SEX  OF  THE  F(ETUS.  151 

commerce  and  the  sciences  flourish,  where  the  air  is  salubrious  and 
the  earth  fertile,  than  in  the  contrary  conditions ;  that  famine  and 
years  of  scarcity,  especially  occasion  extraordinary  changes  in  the 
rate  of  population,  &c. 

In  regard  to  the  faculty  of  procreating  at  will  children  that  shall 
be  beautiful,  endowed  with  great  genius,  and  without  bad  passions, 
I  can  only  refer  the  reader  to  the  Callipedie  of  CI.  Quillet,  to  the 
Megalanthropogenie  of  M.  Robert,  or  lastly  to  the  TraitS  de  la 
Pkilopedie. 


152 


CHAPTER  IV. 

Of  the  Human  Ovum. 

395.  The  human  ovum,  like  that  of  other  mammiferas,  is  com- 
posed of  the  foetus  and  its  appendages. 

ARTICLE  I. 
Of  the  Appendages  of  the  Foetus. 

396.  The  appendages  of  the  foetus  consist  of  the  membranes,  the 
placenta  and  cord,  of  the  umbilical  vesicle  and  allantois,  and  of  the 
liquor  amnii. 

SECTION  1. 
Of  the  Membranes. 

The  covering  of  the  ovum  is  formed  of  three  concentric  layers, 
the  caduca,  the  chorion,  and  the  amnios. 

§.  I.  Of  the  caduca  or  connecting  membrane. 

397.  The  caducous  membrane,  membrana  deddua^  cellulosa,  sin- 
uosa^  spongiosa,  common  or  pre-existing  membrane,  connecting  or 
conjunctive  membrane,  epichorion,  &.C.,  is  so  evident  at  all  periods 
of  gestation,  that  it  must  have  been  noticed  by  every  physiologist 
who  has  paid  much  attention  to  the  examination  of  the  human  se- 
cundines.  Thus,  Areta)us  speaks  of  it  pretty  clearly  under  the 
name  oT  porous  layer ;  Fabricius  under  that  of  membranous  substance 
of  the  placenta ;  G.  Fallopius,  under  the  title  oificshy  substance^  <Sfc.; 
SpigeUus,  under  that  of  the  thick  and  fieshy  portion  of  the  chorion; 
Ruysch  under  that  of  the  velvety  chorion ;  Rouhault,  Littre,  Hobo- 
ken,  under  that  of  chorion  ;  Haller,  under  that  of  external  or  fun- 


CADUCA.  153 

gous  chorion ;  lastly,  Needliam,  Diemerbroeck,  Noorthwyck,  with 
Hoboken,  Rouhault  and  Littre,  have  described  it  by  the  name  of 
chorion,  while  to  the  true  chorion  they  give  the  name  of  allantois  ; 
but  these  obscure  descriptions  were  only  fit  to  hinder  the  researches 
of  observers,  and  can  in  no  respect  be  compared  with  that  given  of 
it  by  W.  Hunter. 

398.  Formation.  Impregnation  determines  in  the  uterus,  a  spe- 
cific irritation,  which  is  promptly  followed  by  an  exudation  of  co- 
agulable  matter,  which  concretes  and  soon  transforms  itself  into  a 
kind  of  sac  filled  with  a  transparent  and  slightly  rosy  fluid.  In 
contact  with  the  whole  extent  of  the  parietes  of  the  uterine  cavity, 
this  kind  of  bladder  or  membrane  continues  in  some  instances 
within  the  origin  of  the  Fallopian  tubes,  and  always  into  the  upper 
part  of  the  cervix,  in  the  shape  of  solid  concrete  cords  ;  it  never  in 
a  natural  state  has  any  opening. 

399.  The  ovule,  after  having  passed  through  the  tube,  necessarily 
depresses  the  caducous  membrane,  so  that  it  may  glide  on  betwixt 
it  and  the  uterus,  to  the  internal  surface  of  which  it  at  last  attaches 
itself;  from  this  moment  the  pre-existing  membrane  is  composed 
of  two  portions  :  one,  very  large,  lining  the  whole  interior  of  the 
womb,  except  the  part  which  is  in  contact  with  the  germ,  bears  the 
name  of  uterine  or  external  caduca  ;  the  other,  very  small,  depressed 
by  the  lower  half  of  the  fecundated  vesicle,  which  it  envelopes,  con- 
stitutes the  reflected  caduca,  internal  caduca  or  epichorion.  The 
extent  of  the  former  augments  in  the  same  ratio  with  that  of  the 
womb,  and  the  aggrandizement  of  the  latter  necessarily  follows  the 
growth  of  the  germ.  Therefore  the  cavity  which  separates  them, 
and  which  is  nothing  more  than  the  altered  cavity  of  the  primitive 
sac,  is  the  greater,  the  nearer  we  are  to  the  first  periods  of  ges- 
tation. 

400.  The  uterine  caduca  preserves  a  pretty  considerable  thick- 
ness, especially  in  the  vicinity  of  the  placenta,  until  the  close  of 
pregnancy ;  the  epichorion*  on  the  contrary,  grows  insensibly  thin- 
ner, so  that  at  the  period  of  labour  it  is  sometimes  of  an  extreme 
tenuity. 

One,  by  sinking  down  into  the  other,  at  length  comes  to  be  in 
contact  with  it,  a  little  sooner  or  later,  about  the  fourth  month, 
for  example  ;  after  this,  the  two  layers  remain  in  a  state  of  more  or 
less  perfect  contiguity  until  the  expulsion  of  the  afterbirth,  with- 
out however  being  even  confounded  together,  notwithstanding  the 
assertions  of  Hunter  and  all  others  who  have  treated  of  this  subject 
tiince  his  day.  It  it  evident,  then,  that  this  membrane  is  managed 
U 


154  APPENDAGES  OP  THE  F(ETUS. 

in  regard  to  the  ovule,  as  the  pleura  is  in  relation  to  the  lung,  or  as 
the  serous  membrane  of  the  pericardium  is  in  respect  to  the  heart. 

401.  The  external  surface  of  the  caduca  is  uneven  and  porous, 
in  contact  with  the  interior  of  the  wonib,  and  invests  the  chorion  as 
far  as  to  the  circumference  of  the  placenta,  but  is  not  prolonged 
over  the  spongy  surface  of  that  body :  to  the  former  its  adhe- 
rence is  very  slight,  is  effected  only  by  means  of  mucous  filaments 
very  easy  to  break,  and  which  certainly  are  neither  vessels  nor  nerves; 
to  the  latter  the  union  is  much  more  intimate,  and  so  much  the 
more  so  as  the  development  of  the  ovum  is  more  advanced.  During 
the  first  two  months  indeed  it  is  pretty  easy  to  extract  the  ovule  from 
that  portion  of  the  sac  which  constitutes  its  epichorion ;  while  at  a 
later  period,  the  numerous  filaments  that  habitually  invest  the  germ 
contract  such  solid  adhesions  with  the  reflected  caduca,  that  it  be- 
comes more  and  more  diflicult  to  effect  this  separation  without  rup- 
ture. 

402.  The  internal  surface  being  moistened  by  a  fluid,  although 
tuberculated,  is  nevertheless  smooth,  and  lined  with  an  extremely 
delicate  pellicle.  After  the  fluid  has  disappeared  and  the  reflected 
portion  has  come  to  be  in  contact  with  the  uterine  layer,  this  sur- 
face soon  assumes  the  characters  of  the  former.  The  liquid  which 
fills  the  cavity  of  the  caduca,  and  keeps  its  two  surfaces  apart,  is 
sometimes  quite  limpid,  but  most  commonly  reddish,  viscid,  similar 
to  melted  glass,  or  rather  to  white  of  eggs,  and  appears  to  be  com- 
posed of  a  large  proportion  of  water,  and  of  albumen,  and  gelatin. 

403.  Circumference.  At  the  place  where  the  caduca  turns  back 
so  as  to  invest  the  ovum,  it  forms  a  circle,  which  at  first  exhibits  the 
form  of  a  fold  more  or  less  regularly  rounded,  but  which  afterwards 
is  gradually  transformed  into  a  thin  and  sharp  edge,  and  ends  at 
last  by  being  more  or  less  evidently  continuous  with  the  circum- 
ference of  the  placenta. 

This  is  a  point  in  the  iiistory  of  tha  connecting  membrane  on 
which  I  most  insisted  in  1824,  and  is,  notwithstanding,  one  on  which 
the  greatest  doubt  has  remained  in  the  minds  of  observers. 

404.  Hunter,  Baillie,  Wrisberg,  Krummacher,  Blumenbach, 
Stein,  MM.  Lobstein  and  Meckel,  Beclard,  &c.  have  indeed  ad- 
mitted the  two  laminae  of  the  caducous  membrane,  but  still  persist 
in  the  belief  that  the  placenta  does  not  fix  itself  to  the  womb  until 
after  having  passed  through  them.  ' 

405.  Chaussicr  and  M.  Duges,  on  the  contrary,  suppose  that  the 
uterus  is  at  first  merely  filled  with  lymph  or  coagulable  albumen ; 
that  the  little  egg,  on  arriving  from  the  ovary,  dips  into  the  midst  of 
this  substance,  and  becomes  covered  with  it ;  that  the  villi  of  the 


CADUCA.  155 

chorion  must  be  confounded  or  blended  with  it  in  order  to  form  the 
placenta,  and  that,  in  consequence  of  the  growth  of  the  womb,  the 
caduca,  at  first  single,  is  separated  into  two  layers.  But  I  now  pos- 
sess so  many  facts  in  favour  of  the  doctrine  laid  down  above,  that  I 
cannot  unite  in  any  respect  with  the  sentiment  of  these  authors. 

406.  Ruysch,  Haller,  the  two  Hunters,  M.  Lobstein,  and  all 
those  who  have  treated  at  some  length  of  the  membrana  caduca,  say 
they  have  met  with  vessels  in  it,  even  in  great  numbers,  and,  conse- 
quently, that  it  is  organized.  I,  on  the  contrary,  do  not  believe  that 
it  is  organized  at  any  period  of  gestation.  It  is  so  easy  to  convince 
one's  self  of  its  organic  condition  by  examining  it  in  a  fresh  after- 
birth, that  I  can  hardly  understand  how  this  remark  has  escaped  the 
attentive  observers  whom  I  have  above  mentioned,  as  well  as  all 
those  who  have  succeeded  them. 

By  examining  it  previously  to  the  end  of  the  second  month,  it  will 
be  found  to  be  soft,  supple,  spongy ;  that  it  is  very  elastic,  tears  with 
extreme  facility,  and  contains  not  a  vestige  of  organic  elements ; 
that  it  is  only  contiguous  to  the  womb,  and  adheres  to  the  chorion 
merely  by  means  of  the  villi  that  always  cover  the  ovule. 

At  the  close  of  pregnancy,  it  preserves  the  same  softness,  the 
same  elasticity  :  it  is  always  of  a  reddish  grey  colour,  easily  reduci- 
ble into  shreds  ;  its  adhesions  to  the  uterus  have  not  undergone  any 
change,  only  its  epichorion  layer  has  become  considerably  thinner, 
in  consequence  of  the  mechanical  distension  it  has  been  subjected 
to ;  its  composition  is  in  all  respects  the  same  as  at  first ;  in  one 
word,  fi-om  the  instant  of  its  formation,  until  its  exclusion  from  the 
sexual  organs,  it  has  never  appeared  to  me  that  the  caduca  could  be 
regarded  in  any  other  light  than  as  a  simple  inorganic  layer ;  how- 
ever, I  can  affirm  that  I  have  carefully  examined  it  in  more  tharf 
four  hundred  specimens  discharged  at  full  term  or  by  abortion. 

407.  It  is  true  that  it  is  sometimes  sprinkled  with  reddish,  stellated 
points,  or  bloody  strias,  which  might,  under  certain  circumstances, 
induce  a  belief  of  the  existence  of  vessels  in  its  substance  ;  we  may 
also  see,  especially  on  its  inner  surface,  an  extremely  delicate  pel- 
licle, which  might  frequently  be  mistaken  for  a  cellular  coat ;  lastly, 
it  also  seems  to  be  pretty  frequently  formed  of  fibres  placed  side  by 
side,  or  even  interlaced  in  various  directions;  but  these  spots,  and 
stria)  of  blood,  no  more  indicate  the  presence  of  vessels  here,  than 
when  they  are  met  with  on  those  membraniform  concretions  that 
are  thrown  off"  by  children  in  croup,  &c. 

408.  If  this  membrane  were  really  organic,  if  it  were  the  seat  of 
a  real  circulation,  can  we  conceive  that  it  would  never  contract  any 
adhesions,  that  it  would  not  be  intimately  blended  with  the  internal 
surfaces  of  the  womb,  and  the  external  one  of  the  chorion,  which  it 


156  APPENDAGES  OF  THE  FCETUS. 

lines  for  nine  months  ?  Finally,  to  decide  the  question,  it  should 
suffice  us  to  remember  that  the  characters  of  this  singular  membrane 
are  in  every  respect  similar,  at  the  moment  of  parturition,  to  what 
they  were  at  the  commencement  of  pregnancy,  a  period  whereift 
nobody  has  pretended  to  have  seen  a  trace  of  organization. 

409.  If  tlien  the  caducous  membrane  is  not  an  organic  membrane, 
if  it  is  merely  an  adventitious  coat,  as  M.  Blainville  calls  it,  or  the 
result  of  a  concretion  taking  place  in  the  uterus,  the  name  of  an- 
histous*  membrane  which  I  propose  to  bestow  upon  it,  and  which 
is  synonymous  with  inorganic  membrane,  appears  to  me  to  be  the 
only  one  that  can  be  advantageously  applied  to  it. 

410.  Uses.  I  shall  not  stop  to  combat  the  opinion  of  those  who 
think  that  the  anhistous  membrane  serves  to  nourish  the  foetus  dur- 
ing the  first  weeks  of  its  existence  ;  to  remark  that  the  umbilical 
cord  is  always  inserted  on  that  portion  of  the  ovule  which  is  not 
covered  with  this  concretion,  ought  to  be  sufficient  to  demonstrate 
that  it  is  unconnected  with  the  nutrition  of  the  first  lineaments  of  the 
foetus.  Its  use  is  to  sustain  the  vesicle  on  some  one  point  of  the 
uterine  cavity.  I  know  it  may  be  objected  that  it  fixes  and  main- 
tains itself  as  firmly  in  animals  as  in  women,  and  just  as  well  in 
extra-uterine  as  in  natural  pregnancy  ;  but  in  brutes,  the  surface  of 
the  ovule,  and  the  form  of  the  parts  through  which  it  has  to  pass,  are 
far  from  being  in  all  respects  similar  to  those  that  are  noticed  in 
the  human  species.  The  uterine  horns  in  brutes  differ  from  the 
human  uterus  in  this  respect,  that  they  never  dilate  enough  to  permit 
the  germ  that  passes  through  or  stops  in  them  to  be  in  contact 
with  all  the  points  of  the  circle  to  which  it  corresponds,  in  one  of 
those  organic  tubes.  Further,  when  the  product  of  fecundation 
accidentally  developes  itself  in  the  peritoneum,  or  the  tube,  or  even 
in  the  substance  of  the  uterus,  it  remains  uniformly  contiguous  to  the 
walls  of  the  cavity  which  it  has  appropriated  ;  so  that  the  caduca, 
such  as  I  understand  it,  is  not  at  all  necessary  in  these  two  circum- 
stances, and  its  absence,  therefore,  does  not  at  all  prove  that  in  re- 
lation to  ordinary  gestation  it  has  not  the  uses  I  have  just  assigned 
to  it. 

Anotlier  use  of  the  anhistous  membrane  seems  to  me  to  be  to 
circumscribe  the  placenta,  and  determine  the  place  of  its  insertion; 
but  I  defer  the  examination  of  this  point  to  another  article. 

411.  Analogy.  Those  who  have  embraced  the  opinion  of  Hun- 
ter have  asserted  that  the  caduca  docs  not  exist  except  in  wo- 
men, and  tiicy  were  so  far  right,  that  it  has  no  where  been  found 
possessed  of  tlic  same  cliaractcrs  it  exhibits  in  the  human  species; 

*  Krom  /(TToc  tela,  and  a.  privulivc. 


CHORION.  157 

l&ut  if,  laying  aside  the  idea  of  a  complete  analogy,  we  are  content 
to  seek  for  its  elements,  more  or  less  modified  in  other  vertebral 
animals,  we  soon  perceive  that  it  is  in  almost  all  of  them  replaced 
by  a  coat  which  is  equally  inorganic.  Thus,  in  the  ophidian  rep- 
tiles its  analogue  is  a  simple  nmcous  induitus ;  in  the  batracians  it 
is  represented  by  a  similar  but  much  thicker  layer ;  in  birds,  not- 
withstanding what  M.  Dutrochet  has  said,  the  calcareous  shell  is  its 
substitute,  and  as  M.  Cuvier  has  already  maintained ;  lastly,  in 
almost  every  species  of  the  mammiferse  there  is  to  be  found  a  lamella 
on  the  external  surface  of  the  chorion,  which  is  sometimes  nearly 
fluid,  at  others  pretty  consistent,  and  of  a  considerable  thickness, 
of  a  greenish  or  yellowish  colour,  and  which  serves  as  a  caduca. 

§.  II.  Proper  membranes  of  the  ovum. 

A.  Of  the  Chorion. 

412.  To  prevent,  for  the  future,  the  chorion  from  being  con- 
founded with  any  other  membrane,  it  will  suffice  to  remember  what 
I  have  just  said  concerning  the  caducous  membrane,  and  that  it 
constitutes  the  first  organized  or  solid  tunic  of  the  ovum  as  we  pass 
from  the  womb  to  the  fcetus,  and  the  second  in  proceeding  from  the 
fcetus  to  the  womb. 

413.  Pnmitive  condition.  In  a  product  of  ten  or  twelve  days 
standing,  the  chorion  presents  the  appearance  of  a  velvet-hke  hyda- 
tid, or  a  small  transparent  vesicle  ;  its  external  surface,  free  from  all 
adhesions,  is  somewhat  fungous  or  fretted  throughout  its  whole  ex- 
tent ;  its  interior  is  filled  with  a  clear  serous  fluid. 

414.  In  products  of  three  or  four  weeks,  the  chorion  is  not  smooth 
on  both  its  surfaces,  as  has  been  erroneously  stated  by  a  multitude 
of  commendable  writers.  I  have  never,  whatever  care  I  may  have 
taken,  seen  it  smooth  exteriorly,  nor  velvety  internally.  At  a  fort- 
night, at  three  weeks,  at  one  month  as  well  as  at  two,  I  have 
always  found  its  external  surface  covered  with  the  same  down,  its 
internal  surface  even  and  polished,  and  its  transparency  neither 
more  nor  less  decided  than  at  any  other  period  of  gestation. 

415.  Granulations.)  and  mllosities.  It  is  generally  thought  that  the 
down  that  covers  the  chorion  is  of  a  vascular  nature ;  but  as  early  as 
1823  I  ventured  to  oppose  this  hypothesis.  What  proves  that  the  fila- 
ments of  the  chorion  are  not  vessels  is  this,  that  they  are  to  be  seen 
before  the  blood  vessels  of  the  cord  are  recognizable.  Besides,  until 
the  sixth  week,  every  flock  is  at  least  as  large  as  one  of  the  umbilical 
vessels :  so  that  as  there  are  only  three  of  these,  it  is  difficult  for 
them  to  give  birth  to  the  others,  which  amount  to  several  hundred. 


158  APPENDAGES  OF  THE  FCETUS. 

Further,  these  villosities,  all  independent  of  each  other,  are  regu- 
larly spread  over  the  whole  periphery  of  the  ovule,  while  the  cord 
and  placenta  are  only  connected  with  one  point  of  this  vesicle ;  and 
notwithstanding  the  efforts  of  an  infinitude  of  very  able  anatomists, 
nobody  has  proved  that  they  are  hollow  rather  than  concrete,  vas- 
cular rather  than  solid  cellular  filaments;  lastly,  when  examined 
with  a  lens,  they  are  found  to  form  certain  areolar  spongioles,  and 
not  permeable  conduits. 

416.  The  abnormal  continuance,  or  preternatural  growth  of  the 
swellings  abovementioned  have  led  me  to  suppose  that  such  hyda- 
tids as  are  found  in  bunches  in  the  womb  are  not  vesicular  worms, 
as  is  commonly  supposed,  but  rather  the  product  of  an  abortive 
ovum,  whose  small  gangliform  bodies  have  taken  on  an  unnatural 
growth.  I  am  in  possession  of  a  considerable  number  of  specimens 
which  sustain  this  view  of  them  :  some  of  them  I  have  shown  to 
M.  Desormeaux,  and  again,  very  recently,  M.  Delange,  physician 
at  Falaise,  has  sent  me  one,  the  examination  of  which  leaves  no 
doubt  on  this  point.  My  opinion  on  this  subject  is  further  fortified 
by  the  cases  of  Albinus,  Wrisberg,  Reuss,  Sandifort,  and  even  by 
those  recently  made  public  by  Madame  Boivin. 

417.  Until  the  third,  fourth  or  fifth  week  of  pregnancy,  the  inner 
surface  of  the  chorion  is  in  contact  with  a  very  delicate  lamella, 
constituting  part  of  a  peculiar  body  which  I  shall,  provisionally,  de- 
nominate the  reticulated  sac.  From  this  period  until  the  sixth  week 
or  second  month,  it  is  no  longer  separated  from  the  amnios  except 
by  a  perfectly  transparent,  vitriform  substance.  In  the  natural  state, 
this  .substance  never  contracts  any  intimate  adhesions  to  any  organ 
capable  of  altering  its  natural  appearances. 

418.  According  to  Needham,  J.  Fabricius,  Noortiiwyck,  Harvey, 
Lacourvije,  Hobokcn,  Littre,  Rouhalt,  &c.  the  thickness  of  the  cho- 
rion is  considerable ;  but  the  error  of  these  anatomists  evidently 
depends  upon  their  having  confounded  the  chorion  and  caducous 
membrane  under  the  same  title. 

I  have  studied  the  ciiorion,  whether  at  term  or  other  periods  of 
pregnancy,  in  a  great  number  of  specimens,  and  have  always  found 
in  my  dissections,  that  it  is  every  whore  transparent  and  thin,  as 
well  upon  the  placenta  as  elsewhere.  This,  indeed,  is  a  fact,  which 
any  one  may  readily  ascertain,  by  taking  care  to  macerate  a  na- 
tural afterbirth  in  water,  so  as  more  easily  to  separate  the  reflected 
caduca  from  it.  Then  the  appearances  of  the  chorion  are  found  to 
bo  exactly  the  same  throughout ;  so  that  the  thesis  of  Phil.  Beclard, 
and  M.  Meckel's  Manual  of  Anatomy  contain  several  manifest  errors 
on  this  subject. 


CHORION.  159 

Hewson,  and  many  who  preoeded  him,  have  asserted  that  the 
chorion  is  formed  of  several  coats,  which,  being  early  applied  to 
each  other,  come  at  last  to  constitute  only  a  single  one  ;  that  the 
placenta  results  from  the  unfolding  and  thickening  of  these  lamince, 
from  which  each  of  the  umbilical  vessels  receives  a  sheath,  &c. 
But  I  have  already  shown,  in  1824,  that  the  reason  of  this 
supposition  probably  depends  upon  the  presence  of  a  concrete 
lamellar  layer,  which  indeed  does  invest  the  vascular  roots  of  the 
placenta,  and  separates  it  from  the  external  surface  of  the  chorion. 
At  present  I  may  add,  that  if  Ruysch,  Haller,  and  so  many  others, 
supposed  the  chorion  to  be  constituted  of  a  variable  number  of 
layers,  it  was  because  they  had  never  separated  it  from  the  mem- 
brana  caduca ;  but  I  do  not  understand  how  MM.  Chevreul,  May- 
grier  and  Dutrochet  could  have  ever  reproduced  this  old  notion. 

At  a  fortnight,  and  at  three  weeks,  as  well  as  at  two  months,  the 
chorion  in  the  human  subject  is  simple,  and  although,  at  a  later 
period,  other  laminae  become  connected  with  it,  they  belong  to  bo- 
dies not  as  yet  described,  and  which  cannot,  under  any  pretext,  be 
considered  as  its  appendages. 

419.  Hippocrates  has  pretended  that  the  membranes  of  the  foetus 
arise  from  the  umbilicus.  Harvey  has  said  that  the  chorion,  the 
amnios  and  chord,  are  merely  prolongations  of  the  child's  belly  ;  and 
Burton,  defending  the  same  opinion,  expresses  himself  still  more 
positively  on  this  subject.  I  myself  related  some  cases,  in  1824,  in 
support  of  such  an  hypothesis.  At  the  same  time  an  Italian  anato- 
mist, M.  Mondini,  contributed  to  strengthen  it  by  meatts  of  some 
particular  researches  and  reasonings.  M.  Moux  states  that  the 
chorion,  after  investing  the  cord,  is  continuous  with  the  derm  of  the 
foetus.  It  should  be  remarked  that  M.  Chevreul  is  of  the  same  opi- 
nion.    Finally,  M.  Blainville  seems  to  have  held  a  similar  opinion. 

But  the  chorion  constitutes  a  part  of  the  ovule  at  the  moment  of 
fecundation  ;  the  abdominal  parietes  are  not  developed  until  after 
the  spine  ;  the  chorion  presents  the  same  characters  and  form  be- 
fore the  appearance  of  the  skin  that  it  exhibits  afterwards  ;  the  cho- 
rion and  the  skin  are  therefore  two  parts  quite  independent  of  each 
other. 

420.  The  chorion  can  be  referred  neither  to  the  derm,  the  mus- 
cles, the  aponeuroses,  nor  peritoneum  ;  however,  it  is  diiRcult  to  call 
in  question  its  cellular  nature,  or  to  deny  its  analogy  with  the 
serous  membranes,  of  which,  besides,  it  presents  all  the  characters, 
whether  physical  or  physiological.  Does  it  contain  nerves  and 
lymphatic,  sanguineous,  exhalant  and  inhalant  vessels  ? 

These  two  last  mentioned  kinds  of  vessels  having  only  been  ad- 
mitted in  animal  bodies  upon  the  say  so  of  the  physiologists,  espe- 


160  APPENDAGES  OF  THE  FCETUS. 

daily  Bichat,  who  never  saw  them,  it  is  good  philosophy  to  reject 
their  existence  without  discussion,  until  they  shall  have  been  demon- 
strated by  more  conclusive  proofs.  The  same  may  be  said  of  the 
lymphatics,  which  the  imagination  alone  of  Schrceger  and  some 
others  seems  to  me  have  detected  in  the  chorion.  As  to  nerves,  I 
think  I  may  say  without  offence  to  Chaussier,  MM.  Ribes,  Home, 
and  Bauer,  that  they  are  no  more  to  be  found  there,  than  the  ex- 
halants  and  lymphatics. 

421.  The  question  in  relation  to  blood-vessels  deserves  much 
more  attention.  Admitted  by  a  great  many  savans  of  the  highest 
merit,  and  that  too  upon  a  certain  number  of  proofs ;  rejected  by 
other  authors  not  less  able,  and  upon  considerations  not  less  powerful, 
it  becomes,  upon  that  account  merely,  very  difficult  to  settle  one's 
opinion  in  relation  to  them. 

In  attempting  to  separate  the  reflected  anliistous  coat  from  the 
exterior  surface  of  the  chorion,  we  soon  perceive  an  indefinite  num- 
ber of  filaments  passing  from  each  one  of  these  laminae  to  the  other, 
and  which  are  more  numerous  as  we  approach  the  circumference  of 
the  placenta,  or  are  nearer  to  thb  commencement  of  the  pregnancy. 
But  these  filaments,  which  Sandifort  and  others  mistook  for  vessels, 
are  nothing  but  the  remains  of  the  villous  tomentum  of  the  ovule, 
and  not  canals  carrying  on  any  circulation  whatever.  The  chorion 
exists  before  the  embryo  ;  with  the  exception  of  the  portion  that  is 
to  support  the  placenta,  it  is  completely  separated  from  the  womb 
by  an  inert  stratum  ;  the  umbilical  and  placental  vessels  do  not  make 
their  appearance  in  the  new  being  until  the  ovule  attaches  itself  to 
the  internal  surface  of  the  uterus  ;  it  is  only,  therefore,  in  the  area 
circumscribed  by  the  reflection  of  the  anhistous  membrane,  that  the 
villi  of  the  chorion  can  allow  any  vessels  to  be  developed. 

422.  The  chorion  is  met  with  in  all  the  vertebral  animals  ;  but 
with  such  modifications  that  most  physiologists  have  been  unable  as 
yet  to  agree  concerning  its  nature  :  in  the  batracian  reptiles,  as  in 
women,  it  forms  the  covering  of  the  ovule  ;  in  the  saurians,  it  ex- 
hibits a  much  greater  thickness  and  solidity,  although  it  has  the  same 
relations  with  the  organs  of  the  female.  In  the  ophidians  it  com- 
poses that  membrane  which  is  so  dense  and  difficult  to  break,  and 
which  constitutes  the  shell  or  outer  covering.  In  birds  the  chorion 
is  much  farther  removed  from  the  vitellus,  and  in  fact  is  not  formed 
until  after  several  other  lamina}.  This  is  the  membrane  that  lines 
the  inner  surface  of  the  calcareous  shell,  and  which  is  known  as  the 
membrane  of  tlic  shell.  Finally,  in  the  mamnnfcrac,  as  well  as  in 
the  human  species,  it  supports  the  placenta  or  the  cotyledons,  and 
throughout  the  remainder  of  its  extent  is  separated  from  the  womb 


CHORION.  ,  161 

or  its  horns,  only  by  an  inorganic  layer  of  variable  consistence  and 
thickness. 

B.  Of  the  Amnios. 

In  the  opinion  of  all  observers,  the  amnios,  also  designated  by  the 
terms  amiculum.,  aguelette^  aurelia^  charta  virginea^  &c.  is  the  inner 
membrane  of  the  human  ovum  ;  smooth,  transparent,  separated  from 
the  foetus  by  the  fluid  virhich  bears  the  same  name,  it  slightly  ad- 
heres to  the  chorion  by  means  of  the  mucous  filaments  or  lamellas 
which  cover  its  outer  surface. 

423.  In  an  abortion  of  from  ten  to  twelve  days.,  for  which  I  am  in- 
debted to  the  kindness  of  Madame  Lachapelle,  and  which  was  only 
four  lines  in  diameter,  I  found  inside  of  the  chorion  a  small  trans- 
parent sac,  on  the  upper  part  of  which  the  microscope  detected  an 
opaque  corpuscle  of  a  whitish  colour.  Did  this  little  sac  represent 
the  amnios  ?     Was  the  white  point  the  embryo  ? 

In  an  ovule  of  twelve  or  fifteen  days.,  presented  to  me  by  M.  Ber- 
mond  of  Bourdeaux,  I  found  fixed  on  a  part  of  the  cavity  of  the  cho- 
rion a  small  transparent  sac,  about  three  lines  long- 
In  another  of  about  three  weeks.,  and  for  which  also  I  am  indebted 
to  the  extreme  complaisance  of  M.  Bermond,  the  amnios  represented 
a  vesicle  three  or  four  lines  in  diameter,  and  was  stuck,  as  it  were, 
on  the  inner  surface  of  the  chorion. 

In  a  fourth  very  perfect  specimen  of  about  twenty  days.,  which 
Madame  Charonnet  was  good  enough  to  give  me  in  April  1825, 
the  ovule,  separate  from  the  reflected  coat  of  the  anhistous  mem- 
brane, measured  only  eight  or  ten  lines ;  the  amnios,  excessively 
delicate  and  white,  was  separated  from  the  embryo  only  by  a  space 
of  a  line  and  a  half,  and  after  being  reflected  along  the  origin 
of  the  cord,  seemed  to  be  continuous  without  any  line  of  demarca- 
tion with  the  integuments  of  the  little  foetus,  which,  further,  was 
well  formed. 

In  an  ovule  of  about  an  inch  in  diameter  aged  three  weeks  or  a 
month,  given  me  by  Madame  Le  Brun,  the  amnios  formed  a  little  sac, 
separated  from  the  foetus  by  a  moderately  thick  stratum  of  fluid, 
and  which  left  the  greater  portion  of  the  cord  exposed  in  the  cavity 
of  the  chorion. 

In  an  ovum  received  from  M.  Fournier,  Surgeon  of  the  Royal 
Stables,  one  which,  from  the  accounts  of  the  woman,  and  the  size 
of  the  chorion,  must  have  been  from  two  months  and  a  half  to  three 
months  old,  but  which,  from  the  size  of  the  embryo,  seemed  not  to 
be  more  than  four  or  five  weeks,  the  amnios  was  a  sac  three  or  four 
times  smaller  than  the  chorion,  and  was  reflected  along  the  cord 
V 


162  APPENDAGES  OF  THE  FOETUS. 

at^e  distance  of  a  line  and  a  half  from  its  root,  so  as  to  give  it  a 
sheath  quite  up  to  the  belly.  This  amnios,  besides,  presented  all  the 
characters  of  the  normal  state. 

In  an  ovum  of  six  or  seven  weeks,  presented  to  me  by  Madame 
Lachapelle,  the  amnios,  nearly  as  large  as  the  chorion,  had  begun 
to  reflect  itself  in  the  form  of  a  funnel  upon  the  cord,  at  the  distance 
of  six  lines  from  the  navel,  which  it  reached  after  enveloping  the 
vessels,  the  pedicle  of  the  vitelline  sac,  the  intestinal  bulb,  &c. 

In  another  older  ovum,  which  was  brought  to  me  by  M.  Morisse, 
an  accoucheur  at  Paris,  the  amnios  was  still  separated  by  a  consi- 
derable space  from  the  chorion,  and  was  applied  to  the  cord  so  as 
to  sheathe  it,  beginning  at  the  place  where  the  prolongation  of  the 
umbilical  cord  was  implanted,  and  extending  as  far  as  the  belly, 
where,  according  to  all  appearances,  it  was  continuous  with  the 
epidermis. 

In  a  specimen  of  eight  or  nine  tceeks,  which  M.  Boulon  d' Abbe- 
ville gave  me,  the  external  surface  of  the  amnios  touched,  so  to 
speak,  the  chorion,  and  invested  the  whole  of  the  cord,  which,  already 
very  long  and  spiral,  still  contained  the  intestinal  mass  in  one  of 
its  enlargements. 

In  one  of  at  least  three  months,  very  perfect,  which  M.  Morisse 
procured  for  me  twenty-four  hours  after  it  had  been  pas^d  by  the 
woman,  the  epidermis  was  so  entirely  separated  from  the  other  parts 
of  the  foetus  by  a  thick  stratum  of  slightly  muddy  serum,  that  it  might 
have  been  removed  with  the  greatest  ease ;  the  same  was  observed 
along  the  cord  from  one  end  to  the  other ;  only  the  pellicle  was  here 
close  to  the  vessels  at  four  different  points,  which  gave  rise  to  four 
contractions  and  four  vesicles  placed  at  equal  distances ;  but  the 
adhesions  of  the  amnios  at  the  contracted  spaces  of  the  umbilical 
cord,  and  those  that  the  epidermis  had  preserved  with  some  portions 
of  the  limbs,  did  not  prevent  me  from  remarking  the  most  perfect 
continuity  between  all  these  lamelte. 

424.  From  these  notions  it  follows,  that  during  the  first  fortnight 
of  gestation,  the  amnios  has  no  immediate  connexion  with  the  foetal 
end  of  the  umbilical  cord,  on  which,  at  a  somewhat  later  period,  it 
doubles,  so  as  to  furnish  it  with  a  sheath,  and  place  itself  in  contact 
with  the  inner  surface  of  the  chorion ;  that  this  disposition  is  main- 
tained, saving  in  a  few  exceptions,  until  the  abdominal  parictes  arc 
completely  formed ;  that  until  then  there  is  no  continuity  between 
the  amniotic  membrane  and  the  epidermis,  but  that  this  continuity 
is  afterwards  difficult  to  deny. 

425.  It  also  follows,  that  the  amnios  is  far  from  touching  the  in- 
ternal surface  of  the  chorion  at  all  periods  of  pregnancy,  as  is  gene- 


AMNIOS.  163 

Tally  supposed,  but  that  these  two  membranes  are,  on  the  contrary, 
separated  from  each  other  by  a  considerable  space,  during  a  period 
which  differs  in  different  individuals. 

This  space^  which  is  at  first  very  large  in  proportion  to  the  cavity 
of  the  chorion,  much  larger  than  the  amnios  itself  during  the  whole 
of  the  first  month,  afterwards  diminishes  by  degrees,  in  proportion 
to  the  increase  of  the  amnios,  so  that  at  two  months  it  about  equals 
that  which  separates  the  embryo  from  its  envelope ;  at  length  the 
disproportional  growth  of  this  last  named  membrane  causes  it  to 
disappear  almost  entirely,  so  that  towards  the  fourth  or  fifth  month 
we  are  obliged  to  suspect,  in  order  to  be  able  to  recognize  its  ex- 
istence. 

426.  It  is  useless  to  repeat  what  I  have  said  as  to  the  non-exist- 
ence of  vessels  in  the  proper  tissue  of  the  chorion,  for  the  purpose 
of  showing  that  they  are  far  more  certainly  wanting  in  the  amnios : 
indeed,  nothing  leads  us  to  admit  of  their  existence  in  the  latter ;  it 
is  never  covered  with  villi  like  the  former ;  it  never  has  any  intimate 
connexion  with  any  vascular  organ,  and  all  that  has  been  said  upon  the 
subject  by  various  authors,  in  fact,  consists  of  mere  assertions,  or 
rather  of  pure  suppositions. 

As  the  remarks  in  this  article  prove  evidently  that  the  amnios 
forms  only  one  single  coat  at  the  various  periods  of  gestation,  I  shall 
not  stop  to  combat  those  who  have  thought  it  to  be  composed  of 
several  layers  in  the  commencement  of  its  development. 

§.  III.  Of  the  water  of  the  amnios. 

427.  Besides  the  fcetus  and  the  cord,  the  amnios  contains  a  fluid 
called  the  water  of  the  amnios^  or  amniotic  liquor. 

428.  At  the  beginning  these  waters  form  but  a  thin  stratum ;  their 
proportional  quantity  afterwards  increases  rapidly,  until  towards  the 
end  of  the  second  month,  when  the  inner  membrane  of  the  ovum 
comes  in  contact  with  the  chorion :  at  three  months  the  weight  of 
the  amniotic  fluid  considerably  exceeds  that  of  the  fcetus ;  but  at 
term  the  weight  of  the  foetus,  in  turn,  considerably  exceeds  that  of 
the  fluid  in  which  it  floats.  At  birth,  in  fact,  there  are  commonly 
not  more  than  from  ten  to  thirty  ounces  of  fluid.  However,  it  would 
not  be  correct  to  say,  with  Madame  Boivin  and  several  others,  that 
the  quantity  of  fluid  diminishes  in  an  absolute  manner  from  the  mid- 
dle of  pregnancy  until  the  moment  of  parturition.  It  is,  on  the 
contrary,  certain  that  it  augments  until  the  close,  but  in  less  pro- 
portion than  at  the  commencement  of  gestation. 

But  in  this  respect  very  great  differences  are  observed  :  instead  of 
one  pound,  there  may  be  two,  four,  and  even  ten  pounds,  or  only  a 


164  APPENDAGES  OP  THE  FffiTtJS. 

few  ounces ;  its  abundance  is  generally  in  an  inverse  ratio  to  the 
vigour,  size,  and  strength  of  the  foetus,  and  robust  constitution  of 
the  woman ;  so  that  a  fcetus  weighing  five  pounds  for  example,  will 
float  in  two,  three,  or  four  pounds  of  the  water,  while  only  three  or 
four  spoonfuls  will  be  found  about  a  child  of  eight  or  nine  pounds 
weight. 

429.  According  to  some  authors,  its  nauseous  insipid  smell  some- 
what resembles  that  of  semen  ;  on  the  whole,  it  is  nearly  similar  to 
that  exhaled  from  the  belly  of  a  slaughtered  animal :  unctuous,  pos- 
sessing rather  more  consistence  than  pure  water,  the  liquor  amnii  is 
clear,  like  simple  serum,  or  of  a  slightly  citron  or  greenish  colour; 
ordinarily  transparent,  it  is  not  unfrequently  lactescent,  thick,  mixed 
with  albuminous  flocks,  of  a  grey,  yellow  or  blackish  colour ;  its 
taste  is  both  sweetish  and  slightly  saltish  ;  in  some  cases  it  is  so  acrid 
and  astringent  as  to  pucker  the  skin  of  the  accoucheur's  fingers, 
when  he  keeps  them  beyond  a  kw  seconds  in  the  vagina  or  womb. 

430.  It  does  not  appear  to  contain  more  animal  matter  in  the  first 
than  in  the  last  half  of  pregnancy,  and  in  this  respect  the  remarks  of 
Harvey,  Lacourvee,  Ruysch,  and  Osiander  seem  to  me  to  be 
wholly  faulty ;  its  chemical  composition  is  very  complicated,  and 
besides,  has  only  been  studied  in  animals.  MM.  Vauquelin  and 
Buniva  found  it  to  contain  :  water,  98.8  ;  albumen,  salts  of  soda 
and  lime,  1.2.  M.  Berzelius  says  that  it  contains  fluoric  acid; 
Scbeele  says  he  found  free  oxygen  in  it ;  M.  Geofiroi  Saint-Hilaire 
admits  that  it  contains  atmospheric  air  in  a  state  of  mixture  ;  but 
MM.  Lassaigne  and  Chevreul,  at  a  later  period,  discovered  that 
what  one  of  them  had  mistook  for  air,  was  nothing  but  a  gas  com- 
posed of  carbonic  acid  and  azote. 

431.  The  chemical  nature  of  the  water  of  the  amnios  diflTers,  as 
has  been  truly  said  by  Van-den-Bosh  from  all  the  other  fluids  of  the 
body.  The  acids,  alcohol,  ebullition  coagulate  it  only  with  great 
difficulty,  or  even  not  at  all :  some  suspect  it  to  contain  a  free  acid ; 
others  an  alkali ;  but  one  of  these  opinions  must  be  incorrect,  for 
acids,  as  is  well  known,  do  not  remain  in  contact  with  alkahes  with- 
out soon  forming  salts.  From  all  the  foregoing,  wo  may  conclude 
that  the  composition  of  the  amniotic  liquid  requires  new  analyses. 

432.  Trusting  to  certain  experiments  of  Monroe,  who  by  inject- 
ing warm  water  into  the  uterine  vessels,  found  it  to  transude  upon 
the  inner  surface  of  the  amnios  ;  to  Ilaller's  assertion  that  the  waters 
become  impregnated  with  the  odour,  colour,  and  even  nature  of  me- 
dicinal substances  taken  by  the  woman  ;  to  the  existence  of  supposed 
vessels  between  the  womb  and  envelope  of  the  ovum,  most  physio- 
logists have  admitted  that  the  liquor  amnii  is  directly  furnished  by 


LIQUOR  AMNII.  165 

the  mother.  Others,  however,  have  maintained  the  contrary,  and 
beheve  with  Scheele,  Winslow,  Van-den-Bosh,  and  M.  Lobstein, 
that  it  comes  chiefly  from  the  foetus,  particularly  from  the  placental 
vessels  ;  Chaussier,  Beclard  and  Meckel  seem  to  hold  a  mixed  opi- 
nion, and  endeavour  to  reconcile  both  the  above  hypotheses. 

433.  Those  who  refer  the  hquor  amnii  to  the  foetus,  have  placed 
its  source  in  the  sweat,  the  insensible  transpiration,  or  the  urinary 
secretion,  or  in  the  glands  or  particular  bodies  of  the  placenta,  or  in 
the  vessels  which  Needham,  Fabricius,  Ruysch  and  Haller  say  they 
observed  betwixt  the  lamellae  of  the  amnios  ;  some  of  the  ancients 
made  of  it  a  coUiquamentum.,  coming  from  the  semen,  &c.  Such  as 
attribute  it  to  the  mother  merely  say  that  it  is  poured  out  by  exha- 
lation in  the  interior  of  the  ovum. 

434.  I  do  not  think  it  would  be  useful  to  refute  these  opinions 
one  by  one  ;  I  shall  content  myself  with  remarking  that  there  is  no 
vascular  connexion  betwixt  the  womb  and  the  membranes ;  that  the 
spongy  coat  is  separated  from  that  organ  by  an  inorganic  layer,  the 
membrana  caduca,  and  that  for  more  than  a  month  the  amnios  does 
not  even  touch  the  inner  face  of  the  chorion,  to  show  that  the  fluid 
in  question  is  not  derived  immediately  from  the  uterus ;  the  propor- 
tional quantity  of  the  liquid  being  much  greater  in  the  first  period 
of  pregnancy,  ought  also  to  sufiice  to  show  that  it  cannot  be  sup- 
posed to  come  directly  from  the  foetus. 

Every  thing  proves  that  the  water  of  the  amnios  is  the  product  of 
a  transudation,  or  of  a  simple  exhalation,  like  the  serosity  of  the 
pleura,  the  pericardium,  the  peritoneum  or  arachnoid,  and  like  the 
synovial  fluid  of  the  tendinous  sheaths,  or  of  the  articulations  ;  and 
that  this  perspiration  does  not  require  for  its  production  the  exist- 
ence of  special  canals ;  that  it  is  an  instance  of  mere  vital  imbibition  : 
the  viscid  matters,  the  muddy  appearance,  the  yellow  or  greenish 
flocks  frequently  met  with  in  it,  do  not  in  any  respect  belong  to  it ; 
for  they  are  nothing  more  than  portions  of  meconium,  or  of  the 
induitus  separated  from  the  foetus,  or  even  of  the  vitriform  substance, 
and  also  of  the  vesicles  which  exist  primarily  between  the  membranes. 

435.  Its  uses  are,  1 .  To  favour  the  active  or  passive  motions  of 
the  foetus,  which,  if  it  were  without  the  liquor,  would  be  every  where 
pressed  by  the  uterus,  and  could  not  develope  itself;  2.  To  permit 
the  isolation  of  the  limbs  and  of  their  diflferent  parts  ;  to  prevent  the 
fingers  from  remaining  in  contact  and  adhering  together ;  to  oppose 
the  adhesion  of  the  fore-arm,  or  of  the  legs  and  thighs  to  the  breast  and 
abdomen,  as  happened  in  a  case  related  by  M.  Morlanne,  where  the 
foetus  was  born  with  such  adhesions  six  weeks  after  the  discharge  of 
the  waters ;  3.  To  protect  the  child  against  the  shocks  and  jars  that 


166  APPENDAGES  OF  THE  FOETUS. 

might  be  experienced  by  the  mother,  and  particularly  by  the  womb  ; 
to  protect  the  tender  being  from  all  kinds  of  compression,  and  to 
furnish  it  with  a  kind  of  tepid  bath  which  might  favour  the  circula- 
tion of  its  fluids,  and  afford  to  it  a  facility  for  moving  according  to  the 
laws  of  gravitation,  and  to  have  the  head  always  directed  towards  the 
neck  of  the  uterus ;  4.  To  keep  the  membranes  always  apart,  main- 
tain the  dilatation  of  the  womb,  and  keep  up  a  gentle  pressure  upon 
the  cord  and  surface  of  the  child ;  5.  In  labour,  to  permit  the  for- 
mation of  the  bag  of  waters,  a  real  segment  of  a  sphere,  which  by 
gradually  engaging  in  the  cervix,  singularly  promotes  its  dilatation  ; 
6.  After  the  rupture  of  the  membranes,  to  lubricate  the  genital  or- 
gans, to  soften  them,  and  thereby  render  the  passage  of  the  head 
easier  and  less  painful ;  7.  Lastly,  to  render  operations  much  more 
simple  and  free  from  danger  when  compelled  to  introduce  the  hand 
into  the  womb. 


SECTION  2. 
Of  the  Vesicles  of  the  Embryo. 

§.  I.  Of  the  umbilical  vesicle. 

436.  The  umbilical  vesicle  is  an  organ  that  was  unknown  to  the 
ancients,  of  which  much  has  been  said  by  the  moderns,  either  with 
a  view  to  place  its  existence  beyond  doubt,  or  on  the  contrary  to 
reject  it  as  among  anomalies  or  pathological  changes^  but  which  has 
not  been  described  so  exactly  as  to  enable  physiologists  to  get  a 
clear  idea  of  it. 

Albinus  was  the  first  author  who  really  observed  it,  and  had  a  draw- 
ing made  of  it ;  if  several  persons  have  supposed  they  could  discover 
some  notions  concerning  it  in  the  works  of  a  remoter  period,  that 
is  because  the  same  anatomists,  having  seen  it  only  a  few  times,  they 
were  often  mistaken  in  regard  to  its  characteristics. 

437.  It  is  wrong,  for  example,  for  MM.  Lobstein,  Beclard  and 
Meckel,  to  carry  the  knowledge  of  it  back  to  the  times  of  Needham 
and  Diemerbroeck,  or  even  of  Ruysch ;  MM.  Oken,  Dutrochet, 
Beclard,  Meckel,  Bojanus,  &c.,  taking  as  a  type  the  one  described 
by  M.  Lobstein,  have  asserted  that  the  umbilical  vesicle  is  at  first 
supported  by  the  front  of  the  embryo  spine ;  that  when  at  its  greatest 
dimensions,  it  may  be  from  four  to  six  Unes  in  diameter ;  and  that  at 
first  its  dimensions  exceed  those  of  the  embryo.  Now  if  it  be  true  that 
many  assertions  emitted  on  this  subject  arc  correct,  it  is  not  less  so, 
that  what  M.  Lobstein  has  observed  does  not  prove  it  to  be  so ;  for  the 
ovum  of  which  he  has  given  a  drawing  being  certainly  in  an  unna- 


UMBILICAL  VESICLE.  167 

tural  state,  all  the  data  resulting  from  the  examination  of  such  a  spe- 
cimen, can  be  of  no  weight  in  science. 

Another  figure  of  the  umbilical  vesicle,  in  the  human  species,  is 
annexed  to  M.  Meckel's  memoir  ;  but  it  must  be  that  the  drawing 
is  a  bad  representation  of  the  original,  or  that  the  original  has  un- 
dergone some  change,  for  the  vitelline  sac,  the  embryo  itself,  and  its 
envelopes  are  not  commonly  disposed  in  that  way  at  the  end  of  the 
fourth  week. 

Among  all  the  drawings  that  have  been  mentioned  by  authors, 
without  excepting  that  of  M.  Dutrochet,  I  am  acquainted  with 
only  two  that  incontestably  represent  the  umbilical  vesicle  in  its  na- 
tural state  in  the  first  six  or  eight  weeks  of  pregnancy  ;  they  are 
those  of  Albinus  and  Soemmering,  and  yet  much  is  wanting,  espe- 
cially to  the  former,  in  a  great  many  respects. 

438.  However,  the  numerous  cases  I  have  collected  enable  me 
to  affirm  that  the  human  ovum  always  contains,  until  the  eighth  week 
of  its  growth,  a  vesicle  similar  or  nearly  similar  to  those  noticed  by 
Albinus,  Soemmering,  MM.  Meckel,  Dutrochet,  &c.  ;  that  if  nu- 
merous naturalists  failed  to  meet  with  it,  it  was  because  they  sought  for 
it  in  specimens  from  which  it  had  disappeared,  either  by  the  natural 
progress  of  pregnancy,  or  by  the  rupture  of  the  membranes  in  the 
abortion,  or  in  consequence  of  some  morbid  state,  or  the  decom- 
position of  the  parts  that  enter  into  the  texture  of  the  ovum,  or 
lastly,  because  they  were  not  sufficiently  practised  in  these  sorts  of 
researches  always  to  detect  it,  though  it  really  existed. 

In  a  total  of  about  one  hundred  and  thirty  specimens,  examined 
before  the  end  of  the  third  month,  I  only  met  with  the  umbilical  ve- 
sicle in  a  state  that  could  be  called  natural,  thirty  times.  I  have  had 
drawings  made  of  six  of  these  vesicles,  and  I  still  possess  some  that 
are  pretty  well  preserved  in  alcohol. 

439.  The  umbilical  vesicle  is  a  small  pyriform  sac  of  a  rounded 
or  spheroidal  shape,  which  about  the  fifteenth  or  twentieth  day  after 
fecundation  is  as  large  as  a  common  pea,  that  is  to  say,  from  two 
to  four  lines  in  diameter.  It  probably  acquires  its  greatest  dimen- 
sions in  the  course  of  the  third  or  fourth  week  ;  at  least,  I  have  al- 
ways found  it  smaller  beyond  the  first  month.  I  confess  I  never 
had  an  opportunity  of  examining  but  one  before  the  first  fortnight, 
and  that  was  also  smaller.  When  reduced  to  the  size  of  a  corian- 
der seed,  which  commonly  takes  place  about  the  fifth,  sixth  or 
seventh  week,  it  generally  ceases  to  diminish,  but  becomes  flattened 
and  then  insensibly  disappears  ;  sometimes  it  can  no  longer  be  found 
at  the  third  month,  while  in  other  cases  it  may  be  met  with  in  abor- 
tions of  four,  five  or  six  months. 


168  APPENDAGES  OF  THE  FOETUS. 

440.  It  is  incontestably  situated  betwixt  the  chorion  and  amnios. 
If  I  maintained  a  contrary  opinion  in  1824,  it  was  because  I  then 
confounded  it  with  a  vesicular  body  which  to  a  certain  extent  re- 
sembles it,  but  which  in  fact  differs  very  widely  from  it,  as  I  shaft 
have  occasion  to  show  in  the  sequel. 

441.  Until  the  fortieth  or  fiftieth  day  it  is  enclosed  in  the  reticu- 
lated body  or  vitriform  layer  ;  after  that  it  unites  with,  and  applies 
itself  either  to  the  internal  surface  of  the  chorion  or  to  the  outer  sur- 
face of  the  amnios.  It  would  seem  then  that  one  of  these  membranes 
encloses  it  betwixt  its  layers ;  indeed  it  is  most  frequently  met  with 
thus,  though  I  have  found  it  perfectly  free  in  ova  of  two  and  even 
three  months. 

442.  The  characters  of  the  pedicle  by  which  it  is  attached  to  the 
embroyo  vary  according  to  the  stage  of  the  pregnancy  :  until  the 
end  of  the  first  month,  and  in  the  natural  state,  I  have  not  found  it 
less  than  two,  nor  more  than  six  lines  long  ;  at  this  period  of  its  de- 
velopment it  is  often  a  quarter  of  a  line  thick,  and  in  becoming 
confounded  with  the  vesicle  undergoes  a  sort  of  infundibuliform  ex- 
pansion. Towards  the  abdomen  it  does  not  enlarge,  neither  does 
it  contract  in  any  sensible  degree.  Its  continuity  with  the  intestinal 
tube  can  now  no  longer  be  called  in  question  in  the  human  subject. 
Before  the  parietes  of  the  abdomen  are  completely  formed,  it  is 
divided,  as  it  were,  into  two  portions  by  the  amnios,  which  it  appears 
to  have  traversed  or  perforated.  One  of  these  portions  is  found 
betwixt  the  spine  and  the  spot  to  be  subsequently  occupied  by  the 
umbilicus  ;  the  other  remains  without,  between  the  amnios  and  the 
vesicle. 

443.  After  the  first  month  the  canal  elongates,  becomes  more 
and  more  delicate ;  its  umbilical  portion  is  lost  in  the  cord,  and  can 
no  more  be  traced  as  far  as  the  belly ;  its  length  may  extend  to  half 
an  inch,  an  inch  or  even  one  inch  and  a  half  Whenever  I  have 
found  the  vesicle  further  than  this  from  the  root  of  the  cord,  it  mani- 
festly depended  upon  its  pedicle  having  been  broken  by  the  trac- 
tions naturally  exercised  upon  it  by  the  membranes  when  theso 
parts  acquire  an  early  and  pretty  strong  adherence  to  each  other. 
Accordingly  as  this  rupture  is  effected  earlier  or  later,  as  the  adhe- 
sions are  stronger  or  weaker,  as  the  pregnancy  is  more  or  less 
advanced,  the  vitelline  sac  is  found  to  be  more  or  less  remote  from 
the  umbilical  cord,  or  if  you  please,  more  or  less  approximated  to 
the  circumference  of  the  placenta. 

444.  This  stem  is  unquestionably  hollow  until  the  twentieth  or 
thirtieth  day,  for  I  was  able  in  two  specimens  to  squeeze  the  liquid 
from  the  vesicle  into  the  intestine  without  rupturing  any  thing ; 


UMBILICAL  VESICLE.  169 

whence  it  follows  that  the  objections  of  MM.  Emmert,  Hoech- 
stetter,  Cuvier,  &c.  are  of  no  value,  at  least  in  so  far  as  they  are 
applicable  to  man.  It  becomes  obhterated  at  a  period  which  has 
not  appeared  to  me  to  be  always  the  same  ;  in  general,  however,  it 
may  be  said  to  be  no  longer  permeable  at  five  weeks,  and  its  oc- 
clusion takes  place  from  the  navel  towards  the  vesicle  in  proportion 
as  the  cord  becomes  more  complete. 

445.  The  parietes  of  the  vitelline  sac  are  strong,  resisting,  pretty 
thick,  and  difficult  to  lacerate  ;  they  have  never  appeared  to  me  to 
be  more  frail  than  the  other  membranes  of  the  ovum,  unless  they 
had  been  previously  rendered  thinner  by  some  morbid  change  or  by 
some  mechanical  cause.  Smooth  and  even  when  the  vesicle  is 
full,  they  wrinkle  or  fold,  on  the  contrary,  when  that  little  body  is 
emptied  ;  they  are  generally  of  a  yellowish  colour,  but  perhaps 
this  tint  depends  upon  the  fluids  they  contain  ;  their  transparency 
too  is  imperfect,  which  may  depend  upon  the  same  cause. 

446.  Those  who  have  examined  the  umbilical  vesicle  in  brutes, 
and  who  have  admitted  its  continuity  with  the  intestines,  pretend 
that  it  is  composed  of  three  lamituB.  According  to  M.  Dutrochet 
the  same  is  observable  in  the  human  species  ;  but,  so  far  as  I  know, 
this  is  only  a  mere  assertion  advanced  without  proof.  However,  as 
to  the  vesicle,  I  have  never  in  any  instance  found  it  to  consist  of 
several  membranes  ;  its  pedicle  in  particular  is  homogeneous  and 
not  lamellated.  So  that  I  think  we  may  very  well  admit  in  this 
apparatus  the  existence  of  a  mucous  surface  and  a  serous  surface, 
but  not  of  a  serous  membrane  and  a  mucous  membrane  ;  still  less 
of  a  muscular  coat:  besides,  it  is  not  until  a  much  later  period  of 
life  that  these  distinctions  of  the  tissues  are  effected,  even  in  those 
organs  where  they  are  subsequently  most  decided  (166). 

447.  However  this  may  be,  arterial  and  venous  vessels  are  visibly 
distributed  upon  it ;  I  have  observed  them  not  only  in  the  substance 
of  the  parietes  of  the  vitello-intestinal  canal,  but  also  in  those  of 
the  vesicle  itself;  in  the  latter  twice,  and  more  than  twenty  times  in 
the  former.  In  the  former  case  I  saw  them  compose  a  very  beautiful 
net  work  with  arborescent  ramifications  extremely  easy  to  follow, 
without  any  particular  preparation,  and  even  with  the  naked  eye. 
In  the  latter,  they  consisted  of  two  trunks  becoming  larger  and 
larger  as  they  approached  towards  the  abdomen. 

448.  These  vessels,  denominated  the  omphalo-mesenteric  vessels^ 
would  be  better  named  vitello-mesenteric,  or  simply  vitelline.  Ac- 
cording to  my  own  observation,  they  do  not  empty  themselves  into 
the  superior  mesenteric  vein  and  artery  ;  I  have  always  remarked 
that  they  join  one  of  the  branches  of  the  second  or  third  order  of  these 

W 


170  APPENDAGES  OF  THE  FCETUS. 

great  vessels,  particularly  those  that  proceed  to  bo  distributed  to 
the  cajcum.  I  have  often  traced  them  in  the  abdomen,  through 
the  umbilical  ring,  and  as  far  as  one,  two,  and  even  three  inches 
along  the  cord,  in  products  of  six  weeks,  and  two  or  three  months 
old.  But  they  disappear  at  these  different  periods,  and  at  last  are 
lost  in  the  spongy  tissue  of  the  umbilical  cord,  before  arriving  at  the 
vesicle.  I  have  several  times  succeeded  in  injecting  them,  and  then 
they  appeared  of  the  size  of  a  large  hair  ;  in  general,  however,  they 
are  so  fine,  that  they  are  easily  broken  if  sought  for  without  the 
greatest  care. 

449.  Inasmuch  as  I  have  seen  them  in  an  ovule  at  the  same  time 
with  the  pedicle  of  the  vitelline  sac,  from  which  they  were  perfectly 
distinct,  it  appears  to  me  they  should  henceforth  be  considered  as 
destined  to  carry  to  and  take  up  from  the  parietes  of  the  vesicle 
and  its  canal,  the  materials  that  serve  for  the  nutrition  of  this  curi- 
ous apparatus  ;  and  not  for  the  transfer  of  the  vitelline  substance 
into  the  general  circulation. 

Many  reasons,  drawn  from  analogy,  have  led  to  a  comparison  be- 
tween the  vitelline  matter  and  the  yelks  or  vitelline  substance  of 
the  eggs  of  birds.  In  the  largest  umbilical  vessel  I  ever  saw,  and 
perhaps  the  only  one  where  there  was  no  possibility  of  this  sub- 
stance having  undergone  any  change  whatever,  it  was  of  a  very  de- 
cided pale  yellow,  consequently  opake,  of  the  consistency  of  a  pret- 
ty thick  emulsion,  and  different  in  all  respects  from  serum  or  any 
other  known  fluid  of  the  economy.  In  others  I  have  found  it  more 
fluid  and  clearer,  and  in  others  yellower  and  thicker ;  in  several  spe- 
cimens it  consisted  of  one  or  two  small  concrete  clots,  resembling  in 
a  remarkable  manner  the  yelk  of  egg  cooked  and  floating  in  a 
slightly  coloured  fluid  ;  to  conclude,  its  colour  is  analogous  to  that 
exhibited  by  the  parietes  of  the  vesicle  itself,  after  the  sixth  week 
of  its  growth.  We  ought,  consequently,  to  admit,  that  it  is  a 
nutritious  substance,  a  sort  of  oil  in  a  great  degree  similar  to  that 
which  constitutes  the  vitelline  fluid  of  the  hen's  egg. 

450.  The  uses  of  this  apparatus  then  are  evidently  connected 
with  the  nutrition  of 'the  primary  lineaments  of  the  foetus;  it  fur- 
nishes to  the  embryo  its  means  of  growth,  until  the  cord  and  um- 
bilical vessels  are  formed,  or  rather  until  the  ovule  becomes  exactly 
applied  to  the  inner  surface  of  the  womb  ;  numerous  materials  then 
pass  from  the  parts  of  the  woman  to  those  of  the  ovum,  and  the 
umbilical  vesicle  soon  becomes  useless.  Under  this  view,  the  appa- 
ratus I  am  speaking  of  can  be  but  temporary,  and  created  to  the 
end  of  giving  time  to  nature  to  establish  with  her  accustomed  gen- 
tleness and  regularity,  the  permanent  means  of  nutrition  in  the  ova 


UMBILICAL  VESICLE.  171 

of  mammiferous  animals.  Frdm  the  moment  of  fecundation  until 
the  ovule  is  found  in  immediate  contact  with  the  inner  surface  of 
the  womb,  the  product  of  human  conception  is  in  almost  all  respects 
similar  to  the  egg  of  a  bird  :  like  it,  free,  and  independent  of  every 
part  of  the  mother,  it  must  contain  whatever  is  necessary  within 
itself;  it  must  contain  a  substance,  by  the  expenditure  of  which  the 
growth  of  the  embryo  can  be  effected,  just  as  the  chick  must  enclose 
within  its  shell  a  material  subservient  to  its  evolution.  But  in  one 
this  arrangement  is  only  transient,  while  in  the  other  it  remains  until 
the  embryo  is  hatched  :  but  this  difference  depends  upon  this,  that 
in  the  former,  incubation  is  performed  in  the  interior  of  a  living 
organ,  an  organ  capable  of  distributing  nutritive  matter  in  abun- 
dance to  the  young  product  within  it ;  while  in  the  second,  it  all 
passes  in  the  open  air,  outside  of  the  parts  of  the  adult  animal. 

§.  II.  Oftheallantois. 

451.  The  allantois  has  by  turns  been  admitted  and  rejected  in 
the  human  ovum,  from  the  earliest  history  of  anatomy  until  our  own 
times,  and  even  now  most  authors  agree  in  rejecting  its  existence. 
All  indeed  who  have  described  it  speak  of  it  merely  from  analogy, 
or  have  mistaken  it  for  an  organ  with  which  it  is  important  that  it 
should  not  be  confounded.  • 

M.  Lobstein  has  described  the  umbilical  vesicle  itself  for  the 
allantois ;  M.  Dutrochet  is  still  farther  from  the  truth  in  taking  for 
this  organ  the  inorganic  pellicle  that  lines  the  interior  of  the  mem- 
brana  caduca.  Lacourvee,  Hoboken,  Diemerbroeck,  Hales,  Nouf- 
ville,  Littre,  Rouhault,  &c.,  affirm  that  they  have  observed  it  at  all 
periods  of  pregnancy ;  some  have  even  given  drawings  of  it ;  but  all 
their  observations  are  referable  to  a  primary  error ;  it  is  the  chorion, 
confounded  anteriorly  to  their  day  with  the  anhistous  membrane, 
that  they  have  described  in  place  of  the  allantois. 

452.  In  an  ovum  of  about  twenty  days  old,  for  which  I  am  in- 
debted to  the  kindness  of  Dr  Terreux,  the  space  between  the  amnios 
and  chorion,  which  was  quite  considerable,  as  it  should  be  in.  the 
first  month  of  pregnancy,  was  almost  entirely  filled  by  a  fungous 
substance  of  a  brownish  yellow  colour,  which  was  less  thick  the 
nearer  it  was  observed  to  the  umbilical  cord,  while  it  was  several 
lines  thick  at  the  point  diametrically  opposite.  Notwithstanding 
this  great  thickness,  it  was  impossible  for  me  to  divide  it  into  seve- 
ral lamina) ;  it  appeared  to  be  formed  of  an  infinite  number  of  fila- 
ments and  lamellae,  disposed  without  regular  order,  but  so  as  to  form 
a  sort  of  reticulated  magma.  By  pressing  upon  it  with  the  dissect- 
ing needle,  I  squeezed  from  it  some  particles  of  a  whitish  pulpy 


172  APPENDAGES'  OF  THE  F(ETUS. 

matter ;  upon  detaching  it  from  the 'chorion,  I  found  it  adhered  to  it 
by  some  very  delicate  and  fragile  filaments  ;  that  its  adherence  to 
the  amnios  and  vitelline  sac  was  less  regularly  established ;  lastly, 
that  it  also  enveloped  the  cord  on  which  the  amnios  was  not  as  yet 
folded,  and  that  it  could  be  traced  to  the  belly  of  the  embryo,  as  far 
as  the  pedicle  of  the  umbilical  vesicle. 

453.  It  is  rare,  exceedingly  rare,  to  have  an  opportunity  of  ex- 
amining so  perfect  a  product  of  conception  ;  M.  Henoque,  however, 
procured  one  for  me  that  was  still  more  so.  This  ovum,  three  or 
four  weeks  old,  and  very  recent,  had  undergone  no  change  of  shape, 
nor  laceration  ;  immediately  under  the  chorion  there  was  a  tissue  of 
a  dull  white  colour,  extremely  delicate,  and  almost  as  easy  to  tear  as 
the  retina.  Notwithstanding  all  the  care  taken,  it  was  ruptured 
merely  by  the  pressure  I  made  upon  another  point  of  the  ovum  in 
dividing  the  chorion.  It  was  full  of  an  emulsive  or  cream-like  sub- 
stance of  a  slightly  yellowish  white,  and  which  tended  to  escape  in 
homogeneous  grumes.  Its  inner  surface  gave  birth  to  fibres  and 
lamella;,  and  to  numberless  prolongations  which  decussated  in  every 
direction,  like  what  is  observable  in  the  spleen,  the  seminal  gland, 
the  corpora  cavernosa,  and  as  is  said  to  be  the  case  also,  in  the 
hyaloid  membrane  of  the  eye.  These  filaments,  after  traversing  the 
semi-fluid  white  matter,  proceeded  to  a  second  lamella,  which,  with- 
out any  intermedium,  was  in  contact  with  the  periphery  of  the  am- 
nios, of  the  umbilical  vesicle,  and  of  its  pedicle.  Certain  isolated 
shreds,  being  washed  and  floated,  exhibited  an  almost  perfect  trans- 
parency, and  much  less  thickness  than  the  amnios. 

454.  To  sum  up,  this  new  organ  constituted  a  sac  with  a  double 
coat,  moulded  upon  the  cavity  of  the  chorion,  enclosing  the  umbili- 
cal vesicle  and  the  amnios,  after  the  manner  of  the  serous  mem- 
branes, forming  interiorly  a  true  net  work  with  lai-ge  unequal  meshes, 
in  which  the  emulsive  fluid  was  lodged.  Its  two  coats,  separated  at 
one  place  by  a  distance  of  more  than  three  lines,  became  more  and 
more  proximate  towards  the  root  of  the  umbilical  cord  ;  near  the 
belly  they  appeared  to  be  confounded  with  each  other,  but  their  ex- 
treme tenuity  prevented  me  from  ascertaining  what  organ  of  the 
abdomen  they  were  continuous  with. 

Have  I  now  any  right  to  conclude  that  this  body  was  really  the 
allantois  ?  It  is  true  I  did  not  succeed  in  demonstrating  its  com- 
munication with  the  bladder,  but  this  communication  has  been  no 
better  demonstrated  in  reptiles,  and  even  in  many  of  tiic  mammifera; ; 
moreover,  the  bladder  itself  was  so  small,  or  so  little  developed  in 
this  specimen,  that  [  am  not  sure  of  having  seen  it ;  besides,  as  on 
the  one  hand  the  summit  of  the  urinary  bladder  naturally  reaches 


ALLANTOIS.  173 

as  far  as  the  umbilicus,  and  as  on  the  other  I  traced  the  reticulated 
sac  from  the  root  of  the  cord  as  far  as  the  navel,  it  was  impossible 
to  make  a  nearer  approach,  without  reaching  it,  or  without  actually 
demonstrating  it,  to  render  this  communication  more  probable. 

In  embryos  more  advanced,  I  have  many  times  traced  the  urachus 
into  the  umbilical  cord,  where  it  unravels  and  is  transformed  into  a 
porous  tissue,  and  terminates  either  in  one  of  the  swellings  when 
they  still  exist,  or  in  the  gelatinous  tissue  of  the  placental  stem  after 
passing  on  for  six  or  eight  lines,  or  one  inch,  or  fifteen  lines.  I  have 
seen  more :  in  an  ovum  of  five  or  six  weeks  old,  the  prolongation 
from  the  bladder  proceeded  to,  and  was  lost  in  the  vitriform  layer, 
which  at  this  period  takes  the  place  of  the  porous  body  of  the  ovule  ; 
I  must  however  confess,  that  having  blown  air  into  the  bladder,  I 
could  not  make  it  penetrate  into  the  urachus,  which  always  retained 
the  characters  of  a  solid  filament. 

455.  From  the  fifth  week  after  conception  until  the  close  of  preg- 
nancy, there  is  betwixt  the  chorion  and  ^nios  *a  transparent  stra- 
tum, either  colourless  or  of  a  somewhat  greenish  red  ;  this  stratum, 
instead  of  being  merely  serous,  is  lamellated  after  the  manner  of  the 
vitreous  body  ;  it  diminishes  in  thickness  in  proportion  to  the  devel- 
opment of  the  other  membranes ;  the  quantity  of  fluid  contained  in 
its  meshes  is,  on  the  contrary,  in  the  inverse  ratio  of  the  progress  of 
gestation  ;  by  diminishing  in  thickness,  it  at  length  comes  to  form 
only  a  homogeneous  pulpy  stratum,  to  transform  itself  into  a  simple 
gelatinous  or  mucous  coating,  which,  in  many  women,  wholly  dis- 
appears before  the  period  of  delivery  ;  several  of  its  lamellae  are 
confounded  together  at  the  external  surface  of  the,  amnios,  princi- 
pally in  the  environs  of  the  root  of  the  umbilical  cord  ;  the  same 
thing  takes  place,  but  more  rarely,  as  to  the  chorion,  which  explains 
why  the  umbilical  vesicle,  observed  after  the  sixth  week  of  gestation, 
is  very  often  united,  as  if  framed  in,  with  the  membranes  of  the  cho- 
rion and  amnios  :  this  matter  occupies  the  place  of  the  reticulated 
body,  and  like  the  latter  is  continuous  with  the  gelatinous  portion 
of  the  cord.  But  is  it  independent  of  the  porous  sac  which  precedes 
it ;  or  rather  is  it  only  a  modification  thereof?  This  last  conjecture 
seems  to  me  to  be,  if  not  certainly  true,  at  least  extremely  probable. 

456.  In  order  to  acquire  more  enlarged  notions  concerning  the 
bodies  in  question,  naturalists  may  advantageously  have  recourse 
to  comparative  anatomy  ;  for  I  have  found  betwixt  the  allantois  of 
oviparous  reptiles,  and  the  reticulated  body  of  the  human  ovum,  the 
most  exact  resemblance. 

In  mammiferas  I  have  observed,  even  at  the  close  of  gestation, 
that  the  urachus,  after  traversing  the  umbilical  cord,  expands  into  a 


174  APPENDAGES  OF  THE  FCETUS. 

smooth  tissue,  that  is  porous,  and  as  it  were,  drilled  full  of  holes, 
which  at  last  unites  intimately  with  the  corresponding  surfaces  of 
the  membranes  between  which  it  is  naturally  placed.  In  this  crib- 
.riform  membrane  we  meet  at  other  periods  with  certain  pelotons  of 
concrete  fatty  matter,  similar  to  the  hippomanes  of  horses  ;  and  as 
the  bladder  opens  into  it,  it  unquestionably  constitutes  part  of  the 
allantois. 

There  are,  therefore,  between  the  sac  known  as  the  allantois  in 
the  mammiferee,  birds,  and  reptiles,  and  the  reticulated  body  which 
I  discovered  in  the  human  ovum,  the  most  striking  agreement  in 
respect  to  resemblance  and  nature. 

457.  In  maintaining  that  the  allantois  is  designed  to  contain  the 
urine  of  the  foetus,  naturahsts  have  in  all  ages  relied  chiefly  upon  its 
communication  with  the  bladder  in  brutes,  upon  the  saline  taste  of 
the  fluid  met  with  in  it,  and,  according  to  Daubenton,  on  the  uri- 
nary smell  observed  in  it.  I  do  not  think  that,  even  in  the  vivipa- 
rous animals,  thesfe  data  are  sufficient  to  establish  such  an  opinion  ; 
the  urinary  odour  is  a  cnaracter  which  is  surely  too  fugacious  for 
us  to  attach  any  great  importance  to  it,  and  on  this  point  is  it  quite 
sure  that  Daubenton  was  not  mistaken  ?  In  the  second  place,  what 
does  the  salt  taste  prove  ?  Do  we  not  meet  with  it  in  the  water  of 
the  amnios  ?  Was  it  not  communicated  by  the  last  named  fluid  to 
the  former  ?  What  connexion  can  there  be  between  tlie  urine  and 
the  viscid,  fatty,  whitish  matter  contained  in  the  allantois  of  the  bi- 
sulca) ;  between  the  urine  and  that  white,  feculent  and  reticular  mass 
contained  in  the  allantois  of  the  chick  about  the  tenth  day  of  incu- 
bation ;  between  the  urine  and  the  milky,  flaky  fluid  I  have  observed 
in  the  ovum  of  an  adder  ?  Certainly  none  :  to  contain  the  urine  is 
not  the' only,  is  not  even  the  chief  use  of  the  allantois. 

As  to  the  human  species,  whether  the  reticulated  body  is  analo- 
gous to  the  allantois,  or  constitutes  a  different  organ,  whether  it 
communicates  with  tlie  bladder  by  means  of  some  channel,  or  is 
independent  of  it,  it  appears  to  me  impossible  to  establish  the  least 
affinity  between  the  substance  found  in  it  and  the  urinary  fluid. 

Its  functions,  like  those  of  the  reticulated  body,  are  in  my  opinion 
connected  with  the  early  nutrition  of  the  germ.  Perhaps  it  serves 
for  tiic  development  of  some  particular  organ,  or  some  special  appa- 
ratus ;  on  this  subject  wc  may  indulge  in  a  thousand  conjectures ; 
but  fearing  to  stray  in  the  field  of  suppositions,  I  prefer  to  wait  for 
new  facts,  I  shall  content  myself  with  showing  that  the  inner  sur- 
face of  the  shreds  1  have  turned  back  on  it,  were  covered  with  an 
adherent  layer  of  a  crcam-likc  matter  contained  in  its  interior ;  that, 
m  the  microscope,  it  presented  a  villous  appearance,  and  that  from 


ALLANTOIS.  175 

this  double  peculiarity  it  is  probable  that  the  substance  in  the  reti- 
culated body  is  secreted  by  its  own  parietes.  This,  moreover,  would 
be  an  argument  in  favour  of  the  opinion  of  Harvey,  of  Joerg,  and  of 
Oken,  in  relation  to  the  fluid  of  the  allantois  in  animals.  1  will  ob- 
serve further,  that  this  matter  preserves  its  cream-like,  flaky  aspect, 
its  appearances  of  an  emulsive  fluid,  its  characters  of  a  nutritive 
substance,  until  the  ovule  is  well  fixed  in  the  womb,  and  then  dis- 
appears very  rapidly,  giving  place  to  the  albuminous  stratum,  which 
remains  until  the  termination  of  pregnancy.  I  make  no  mention 
here  of  a  third  vesicle  described  in  the  Isis  by  M.  Pockels,  under 
the  title  of  the  erythroid  vesicle^  because  I  have  never  noticed  it,  and 
because  I  behove  the  author  is  mistaken  in  relation  to  it. 


SECTION  3. 
Of  the  Cord  and  Placenta. 

§.  I.  Of  the  umbilical  cord  (^funiculus  umhilicalis). 

458.  The  umbilical  cord  is  a  stem  by  which  the  abdomen  of  the 
foetus  is  conjjected  with  the  membranes  of  the  ovum,  from  the  com- 
mencement flntil  the  end  of  pregnancy. 

459.  Its  length,  although  variable,  is  notwithstanding  generally 
the  same  as,  or  a  little  greater  or  less  than  that  of  the  fcBtus  at  birth, 
that  is  to  say,  from  fifteen  to  twenty  inches.  Denman,  L'Heritier,  and 
MM.  Morlanne  and  Maygrier,  have  spoken  of  cords  measuring  four, 
five,  and  even  six  feet  in  length ;  others  have  been  seen  only  a  fow 
inches  long,  which  even  retained  the  placenta  in  contact  with  the 
fcEtus  ;  but  these  extremes  of  dimension  are  rare,  and  some  of  the 
notices  of  them  require  to  be  repeated. 

4 GO.  Some  times  thicker,  at  others  more  slender,  it  generally  is 
about  the  size  of  the  little  finger.  In  this  respect  its  anomalies, 
which  are  much  more  apparent  than  real,  depend  upon  whether  the 
spongy  tissue  of  which  it  is  partly  composed  is  engorged  with  fluids 
which  constitutes  fat  cords^  or  on  the  other  hand  almost  entirely 
desiccated,  and  then  the  cord  is  lean.  However,  they  may  also  de- 
pend upon  varieties  in  the  absolute  thickness  of  their  vessels  or 
sheaths. 

4G 1 .  Although  smooth  and  polished  like  the  serous  membranes,  the 
human  cord,  nevertheless,  exhibits  many  nodosities  of  different  kinds, 
on  which  I  must  dwell  for  a  moment :  on  some  occasions  they  are 
real  knots,  either  simple  or  complex  ;  more  frequently,  however, 
they  are  doublings,  vascular  nooses,  whether  of  the  arteries  or  of 


176  APPENDAGES  OF  THE  F(ETUS. 

the  vein  ;  the  former  are  met  with  particularly  where  the  cord  is  very 
long,  are  owing  to  the  movements  of  the  foetus,  are  effected  in  the 
same  way  as  the  twisting  of  the  cord  about  the  neck,  limbs,  or  other 
parts  of  the  child,  frequently  met  with  in  parturition,  and  it  may  be 
said  are  but  the  definitive  result  of  this  last  mentioned  disposition. 

The  second,  known  in  all  ages,  are,  according  to  Harvey,  more 
frequently  formed  by  the  vein  than  by  the  arteries  ;  but,  according 
to  my  own  researches  and  those  of  Hoboken,  more  frequently  by  the 
arteries  than  by  the  vein :  being  produced  by  the  folding  of  one  or 
both  these  vessels,  after  the  manner  of  the  varicose  knots  in  other 
parts  of  the  body,  there  may  be  only  one  or  several  of  them  on  the 
same  cord.  Rhodion  and  Avicenna  among  the  ancients,  and  the  old 
women  of  all  periods,  pretend  that  by  means  of  the  number  of  these 
knots,  their  remoteness  from  or  nearness  to  each  other,  and  their 
colour,  it  is  possible  to  ascertain  the  number  and  sex  of  the  children 
the  woman  is  to  have  in  future,  the  interval  between  each  of  the 
confinements,  &c.  These  ridiculous  pretensions,  begotten  by  the 
superstition  of  our  ancestors,  doubtless  do  not  deserve  to  be  seri- 
ously opposed  ;  but  they  are  so  often  met  with  among  the  public,  that 
I  thought  they  ought  not  to  be  passed  over  in  silence.  Although 
they  have  never  been  accused  of  interfering  with  the  omphalo-pla- 
cental  circulation,  it  may  nevertheless  be  concluded*  that  if  very 
numerous  and  close,  and  presenting  very  acute  angles,  these  turn- 
ings might  be  the  means  of  obstructing  to  a  greater  or  less  degree 
the  flow  of  the  blood  in  its  proper  vessels. 

462.  The  point  of  the  belly  which  gives  insertion  to  the  umbilical 
cord,  is  at  a  greater  distance  from  the  breast,  or  nearer  the  pubis, 
in  proportion  as  the  pregnancy  is  less  advanced.  At  birth,  it  gene- 
rally corresponds,  according  to  Chaussier  and  M.  Bigeschi,  to  the 
middle  of  the  space  between  the  vertex  and  soles  of  the  feet.  It  or- 
dinarily terminates  in  the  centre  of  the  placenta;  but  it  is  also  some- 
times found  attached  very  near  the  circumference  of  that  body  :  in 
the  former  case,  the  branches  of  which  it  is  composed  diverge  by 
expanding  in  the  covering  of  the  ovum  ;  in  the  latter,  it  is  not  a  rare 
occurrence  to  find  it  creeping  betwixt  the  membranes  a  longer  or 
shorter  time  before  it  is  lost  in  the  placental  parenchyma.  Of  an 
equal  size  throughout  its  whole  extent  in  some  subjects,  it  is  in  others 
much  more  slender  near  its  root  than  near  the  abdomen,  and  reci- 
procally. 

4G3.  Development.  Trusting  to  false  analogies,  hypothetical 
data,  or  careless  observations,  authors  have  asserted  that  it  does  not 
begin  to  bo  distinct  until  after  the  first  month  of  gestation.  The 
youngest  embryos  I  have  ever  disaected  had  the  umbilical  cord.     I 


UMBILICAL  CORD.  177v 

am  now  in  possession  of  several  of  from  one  fortnight  to  three  weeks 
old,  which  are  only  three  or  four  lines  long,  and  in  which  the  cord 
is  equal  to,  or  even  exceeds  the  length  of  the  foetus.  Relying  upon 
very  numerous  facts,  I  think  I  can  establish  it  as  a  general  rule,  that 
the  length  of  the  cord  is  about  equal  to,  or  somewhat  exceeding  that 
of  the  fcetus,  at  all  periods  of  pregnancy. 

It  is  slender  and  cylindrical  until  the  end  of  the  third  week  :  a 
little  later,  from  the  fourth  to  the  seventh,  the  eighth,  or  even  the 
ninth  week,  it  acquires  a  considerable  relative  size,  exhibits  tuber- 
cles, vesicles  or  swellings,  which  I  have  no  where  seen  described, 
which  are  to  the  number  of  two,  three  or  four,  and  separated  by  the 
same  number  of  contractions.  In  the  course  of  the  third  it  becomes 
smaller,  in  consequence  of  the  shrinking  away  of  its  swellings; 
finally,  from  this  period  until  the  termination  of  pregnancy  it  ceases 
to  grow  in  proportion  to  the  other  parts  of  the  fcetus. 

464.  Its  composition  is  far  from  being  the  same  at  all  stages  of  its 
evolution.  At  the  commencement,  it  really  consists  only  of  a  small 
solid  cylinder,  to  which  the  amnios  does  not  furnish  any  coat.  From 
the  fifth  week  it  contains  the  duct  of  the  umbilical  vesicle,  and  a  por- 
tion of  the  urachus  or  allantois,  and  some  of  the  intestines.  But 
about  the  second  month,  the  alimentary  canal  has  re-entered  the 
abdomen,  the  urachus,  the  vitelline  duct  and  its  vessels  have  become 
obliterated,  so  that  at  three  months,  as  at  nine,  the  umbilical  stem  is 
formed  only  of  two  arteries,  the  vein  of  the  same  name,  of  the  gela- 
tin of  Warthon,  or  spongy  tissue  of  Rouhault,  and  of  the  amniotic 
sheath. 

465.  Diemerbroeck,  Wrisberg,  Schrceger,  and  MichjElis  have  ad- 
mitted the  existence  of  lymphatic  vessels  in  the  cord ;  MM.  Chaus- 
sier,  Darr,  Reuss,  &c.  think  they  have  discovered  nerves  in  it  going 
to  the  solar  plexus ;  but  it  is  probable  these  authors  permitted  them- 
selves to  be  imposed  on  by  some  remains  of  the  urachus,  the  vitel- 
line vessels  or  duct,  &c.  At  least  I  have  never  been  able,  with  all 
the  pains  I  could  take,  to  verify  their  assertions  ;  a  circumstance  in 
which  my  researches  agree  with  those  of  MM.  Lobstein  and  Meckel. 

466.  Although  there  is  in  man  only  one  umbilical  vein,  as  an 
ordinary  rule,  cases  are  cited  where  there  were  two,  as  occurs  in  a 
great  many  of  the  mammiferse.  In  other  cases,  instead  of  two  arte- 
ries, only  one  is  found  ;  I  have  seen  an  instance  of  this  sort,  and  M. 
Blandin  has  deposited  a  second  in  the  museum  of  the  Faculty. 

These  vessels  are  not  visible  until  the  first  fortnight,  or  the  second 

month  after  conception,  and  do  not  assume  the  spiral  form  until  after 

the  disappearance  of  the  swellings  of  the  cord,  that  is,  from  the 

seventh  to  the  eighth  week.     The  reason  of  this  twisted  appearance 

X 


178  APPENDAGES  OF  THE  FCETUS. 

seems  to  me  to  be  very  plain  :  it  depends  on  the  rotatory  movements 
of  the  child  in  the  womb,  and  ten  times  out  of  twelve  it  turns  from 
left  to  right,  according  to  my  own  and  Meckel's  observations.  In 
some  subjects,  the  cord  is  turned  in  one  direction  near  the  placenta, 
and  in  the  opposite  one  near  the  child's  belly  ;  most  frequently  it 
looks  hke  a  real  rope,  and  hence,  doubtless,  is  derived  its  name, 
cord.  Sometimes  all  three  of  the  vessels  turn  on  one  ideal  axis ;  at 
others  the  vein  is  twisted  round  the  arteries,  but  in  general  the 
arteries  are  twisted  round  the  vein, 

467.  It  is  altogether  incorrect  to  say  with  Hoboken,  Reuss  and 
some  other  anatomists,  that  there  are  valves  in  the  umbilical  vein ; 
I  have  been  convinced  of  the  contrary  a  hundred  times  by  careful 
dissection.  Rouhault  has  remarked  that  the  dimensions  of  this  vein 
are  double  those  of  both  the  arteries. 

The  common  sheath  that  envelopes  them  continues  transparent  for 
about  two  months,  and  during  this  period  permits  us  very  distinctly 
to  see  them  in  its  centre ;  after  which  it  grows  more  and  more 
opaque  as  the  pregnancy  advances.  I  have  already  said  that  it  does 
not  exist  at  the  commencement ;  it  is  seen  to  form  by  degrees  be- 
tween the  first  and  the  end  of  the  second  month,  progressing  from 
the  embryo  towards  the  root  of  the  cord  in  the  following  manner : 
the  amnios,  at  first  much  smaller  than  the  chorion,  and  as  if  pierced 
with  a  circular  hole,  to  allow  the  pedicle  of  the  vitelline  sac  and 
umbilical  vessels  to  penetrate  into  the  abdomen,  is  afterwards  re- 
flected along  the  umbilical  cord  as  the  ovum  enlarges,  but  so  as  not 
to  afford  a  complete  sheath  to  its  vessels  until  the  tunics  of  the  foetus 
come  into  contact  with  each  other. 

468.  Notwithstanding  that  these  vessels  do  not  in  general  sepa- 
rate or  divide  until  they  reach  the  placenta,  it  would  be  a  mistake  to 
suppose  they  never  do  so.  Their  division  may  take  place  at  the 
distance  of  one,  two  or  four  inches  from  the  inner  surface  of  the 
chorion,  and  even  very  near  the  abdomen  of  the  child.  In  this  case 
their,  first  divisions,  diverging  like  tlie  rays  of  a  parasol,  fall  upon 
points  pretty  near  the  circumference  of  the  placenta.  Examples  of 
this  kind  have  been  figured  by  various  authors.  I  have  seen  one 
belonging  to  M.  Deneux,  and  have  two  of  my  own.  Those  obser- 
vers,'who,  like  Van-der-Wiel,  Schurig,  &c.  have  supposed  that  a 
single  fojtus  might  have  more  than  one  umbilical  cord,  have  pro- 
bably been  misled  by  this  anomaly,  for  it  is  pretty  nearly  certain  that 
two  cords  never  existed  in  the  same  subject. 

469.  In  the  scientific  collections  fnay  be  found  facts  tending  to 
prove  that  the  belly  is  not  tiie  only  point  to  which  the  cord  may  bo 
attached  ;  that  it  lias  been  seen  inserted  upon  the  breast,  the  neck, 
the  limbs,  &lc.     But  none  of  these  observations  are  of  a  nature  to 

f 


UMBILICAL  CORD.  179 

enforce  conviction  ;  they  should  be  received  with  great  reserve,  for 
they  rather  give  evidence  of  the  credulity  of  their  authors,  than  of  what 
they  wish  to  prove.  However,  there  is  at  Brussels,  in  the  anatomical 
museum  of  a  gentleman  of  that  city,  a  foetus,  with  the  cord  inserted 
upon  the  cranium,  and  which  M.  J.  Cloquet  has  had  an  opportunity 
of  examining.  If  I  might  speak  of  a  thing  I  have  never  seen,  I 
should  say  the  abnormal  cord  originally  belonged  to  a  second  foetus, 
and  became  accidentally  attached  to  the  cranium,  that  the  natural 
cord  also  existed,  and  that  the  cranial  cord  did  not  penetrate  be- 
yond the  integuments  :  I  have  seen  one  case  that  might  give  rise  to 
ideas  similar  to  those  I  am  now  combating.  A  monstrous  foetus, 
born  at  the  seventh  month,  and  for  which  I  am  indebted  to  the 
goodness  of  Madame  Jagu,  had  the  umbilical  cord  so  disposed,  that 
at  first  view  there  seemed  to  be  four  of  them  ;  two  of  them  depart- 
ing from  the  belly  and  the  other  two  from  the  breast.  But  it  was 
only  a  natural  cord,  doubled  several  times,  and  the  angles  of  the 
folds  of  which  had  adhered  to  the  membranes  and  also  to  the  skin 
of  the  foetus. 

§.  II.  Of  the  placenta  (Jwpar  uterinum). 

470.  The  placenta^  thus  named  by  Fallopius  from  its  resem- 
blance in  shape  to  a  flattened  cake,  is  that  part  of  the  ovum  which 
is  found  in  immediate  contact  with  the  organs  of  the  mother,  and 
is  continuous  at  its  circumference  with  the  reflected  caduca.  It  is 
only  found  in  the  mammiferous  animals,  where  it  exhibits  very  va- 
rious shapes.  In  the  dog  it  is  a  complete  zone  surrounding  the  en- 
tire chorion  ;  the  placenta  of  the  ruminating  animals  is  multiple, 
and  presents  itself  to  the  view  of  the  observer  under  the  appearance 
of  unequal  and  pcdicillate  masses.  In  the  rodentia  it  is  composed 
of  a  circular  plate  formed  of  two  layers,  which  are  to  a  certain  extent 
dissimilar.  In  the  horse  it  consists  of  a  simple  reddish  and  granular 
layer,  which  covers  the  whole  extent  of  the  chorion.  In  the  hu- 
man species  where  I  have  particularly  to  examine  it,  it  is  a  softish 
and  spongy,  flattened,  circular,  oval  or  reniform  body  ;  its  width,  or- 
dinarily from  six  to  eight  inches,  is  sometimes  smaller  and  at  others 
greater.  Its  thickness  is  also  very  variable,  and,  moreover,  very  un- 
equal in  different  parts  of  the  same  one ;  generally  from  one.  inch  to 
an  inch  and  a  half  at  the  centre,  it  goes  on  lessening  towards  the  cir- 
cumference, which  is  frequently  only  a  few  lines  in  thickness,  but 
which  is  occasionally,  in  some  points,  thicker  than  the  centre  itself. 

As  its  diameters  are  from  six  to  eight  inches,  it  is  useless  to  say 
that  its  circumference  is  from  eighteen  inches  to  two  feet. 

471.  One  of  its  surfaces,   the  fatal,  inner,  smooth,  vascular^ 


I 


J 80  APPENDAGES  OF  THE  FCETUS. 

memhranms^  &c.  surface,  is  lined  by  the  chorion,  which  adheres  to 
it,  and  by  the  amnios,  which  can  always  be  separated  from  it  by 
merely  peeling  it  off.  Tn  spreading  upon  it,  the  principal  divisions 
of  the  vessels  of  the  cord  form  a  very  beautiful  diverging  net  work. 
472.  Its  other,  external  or  uterine  surface,  viewed  in  the  womb 
or  upon  an  entire  ovum,  appears  porous  and  fungus-like,  but  even  ; 
neither  cracks  nor  orifices  of  sinuses  are  seen ;  it  only  exhibits  a 
few  salient  points ;  the  anhistous  membrane  does  not  cover  it ;  a 
simple  pellicle  lines  it  and  covers  its  lobes. 

When  the  placenta  is  out  of  the  womb,  this  surface  is,  on  the 
contrary,  extremely  uneven  ;  lobes  of  various  sizes  are  seen  upon 
it,  and  they  are  separated  by  fissures  of  greater  or  less  depth  ;  and 
this  happens  because,  in  detaching  and  expcUing  the  placenta,  the 
uterus  by  doubling  it  up  lacerates  the  thin  inorganic  pellicle  which 
concealed  the  intervals  between  its  numerous  cotyledons. 

I  have  had  six  opportunities  of  observing  it  in  situ^  and  in  none 
of  them  could  I  discover  either  sinus  or  opening  having  the  least 
resemblance  to  what  authors  have  described  as  such.  It  is  proba- 
ble that  the  observers  have  been  deceived  by  some  accidental  open- 
ings and  excavations,  such  as  are  often  met  with,  but  which  are 
owing  to  the  pellicle,  before  mentioned,  being  lacerated  here  and 
there,  and  rendering  it  an  easy  matter  to  penetrate  into  the  placental 
fissures,  as  into  so  many  excavations. 

At  the  full  term  of  pregnancy,  the  circumference  of  the  placenta 
is  continuous,  without  any  decided  line  of  demarcation,  with  the 
double  layer  of  the  caducous  membrane  ;  and  this  is  doubtless  what 
has  led  to  the  belief  that  the  first  mentioned  part  of  the  ovum  is 
only  a  thickened  portion  of  the  latter. 

473.  Arantius,  Hoboken,  Warthon,  Ruysch,  Malpighi,  and  many 
other  old  writers ;  Wrisbcrg,  Rcuss,  MM.  Lobstein,  Meckel,  &c. 
among  modern  ones,  have  made  many  attempts  to  unveil  the 
nature  or  structure  of  the  placenta.  It  might  be  supposed  that  in 
this  respect  science  has  nothing  more  to  desire  ;  but  in  turning  over 
the  most  esteemed  works  on  the  subject,  one's  opinion  is  soon  alter- 
ed, on  perceiving  that  twenty  different  sentiments  yet  have  their  an- 
tagonists and  defenders. 

Warthon,  opposed  by  Arantius,  was  one  of  the  first  to  say  that 
the  placenta  consists  of  two  halves,  one  uterine  or  maternal,  and  the 
other  membranous  or  foetal.  If  Warthon,  and  those  who  have 
adopted  this  division  of  the  placenta  have  not  taken  the  ovum  of 
tho  rodcntia  as  ihcir  model,  I  am  unable  to  discover  in  the  human 
aflcr-birth  any  appearances  that  could  account  for  their  mistake  ; 
which  besides  has  been  imitated  by  many  of  tho  moderns. 


PLACENTA.  181 

It  is  sufficient  to  cast  a  glance  on  the  porous  surface  of  any  pla- 
centa, to  be  convinced  that  one  of  its  halves  has  not  remained  ad- 
herent to  the  uterus ;  to  remark  that  this  surface  is  smooth,  and 
covered  with  a  thin  lamella,  noticed  even  by  those  who  admit  the 
double  layer,  in  order  to  see  that  the  fact  is  not  so,  and  indeed  can 
not  be  so,  &c. 

474.  This  membranule,  which  covers  the  fungous  surface  of  the 
placenta,  admitted  by  Arantius,  Littre,  Hunter,  MM.  Lobstein, 
Chaussier,  Meckel,  and  most  of  the  modern  anatomists ;  rejected 
by  Ruysch,  Mery,  Rouhault,  &c.  seems  to  me  to  have  been  gene- 
rally ill  understood  :  some,  contrary  to  the  opinion  of  Wrisberg, 
have  thought  it  to  be  only  a  thin  portion  of  the  caduca  ;  according 
to  most  observers,  it  contains  many  vessels  ;  many  authors  state 
that  it  passes  directly  from  one  lobe  of  the  placenta  to  another 
without  dipping  down  into  the  interval  between  them  ;  a  still  great- 
er number,  on  the  contrary,  pretend  that  it  dips  down,  also,  between 
the  cotyledons,  betwieen  each  bundle,  and  every  vascular  filament, 
to  which  it  furnishes  a  kind  of  sheath.  Lastly,  there  are  some  who 
believe  in  its  existence  during  the  whole  period  of  pregnancy  ;  while 
others  say  they  have  only  met  with  it  in  the  three  or  four  last 
months. 

As  long  as  the  placenta  does  not  form  a  compact  mass,  that  is, 
until  about  the  twelfth  week,  there  is  not  a  trace  of  the  pellicle  in 
question ;  as  soon  as  the  tomentose  groups  of  the  chorion  become 
entirely  agglomerated,  it  appears,  as  if  to  cover  their  summits,  and 
soon  afterwards  is  found  to  be  continuous  and  confounded  with  the 
reflected  edge  of  the  anhistous  membrane. 

It  certainly  contains  no  vessels,  and  the  idea  of  a  circular  venous 
sinus,  which  according  to  the  reports  of  certain  anatomists  exists 
along  the  circumference  of  the  placenta,  can  only  be  the  result  of 
a  careless  observation. 

The  utero-placental  pellicle  is  here  disposed  in  the  same  manner 
as  the  arachnoid  is  on  the  brain  :  on  the  top  of  the  projections  and 
protuberances  it  adheres  intimately  ;  whilst  opposite  to  the  spaces 
betwixt  the  lobes  it  may  be  easily  separated,  in  the  shape  of  a  deli- 
cate, transparent  lamella ;  like  the  arachnoid,  it  also  remains  on 
the  surface,  and  in  general  does  not  penetrate  into  the  parenchyma. 
Its  nature  is  similar  to  that  of  the  peUicles,  which  soon  after  their 
formation  cover  almost  all  sorts  of  fibrinous  concretions.  It  is 
not  a  tissue  ;  it  is  destroyed  by  placing  it  in  water,  and  after  a  few 
hours  dissolves  as  readily  as  all  the  other  membraniform  concre- 
tions. 

475.  A  coat  of  deposit^  much  thicker,  more  fragile,  and  not  so 


182  APPENDAGES  OF  THE  F(ETUS. 

smooth  as  the  preceding  one,  surrounds  all  the  vascular  trunks  ; 
this  is  what  has  given  occasion  to  the  belief  that  the  vessels  of  the 
placenta  ramify  in  the  very  substance  of  the  caduca ;  that  the  chorion 
is  composed  of  several  coats ;  that  the  anhistous  membrane  lends 
one  lamina  to  the  external  and  another  to  the  internal  surface  of 
the  placenta,  and  that  the  delicate  pellicle  of  the  latter  is  doubled 
down  between  all  the  fibrillas  of  its  lobes  and  lobules.  The  lamellEB 
of  which  it  is  composed  appear  to  me  to  be  a  concreted  product 
of  a  peculiar  exudation  from  the  womb,  the  chorion,  and  its  to- 
mentose  portion.  In  this  respect  there  is  some  analogy  between 
them  and  the  caduca  ;  but  they  differ  from  it  in  this,  that  they  are 
not  to  be  seen  until  a  long  time  after  the  ovum  has  reached  the 
uterus,  while  the  anhistous  sac  forms  immediately  after  fecundation  ; 
and  also  in  this,  that  one  is  very  soft  and  somewhat  elastic,  while 
the  others  are  dry,  hard,  and  break  almost  as  easily  as  glass. 

47G.  The  glandular  bodies,  to  which  Blancardi,  Malpighi,  and 
Littre  attributed  important  functions  in  the  placenta,  are  no  longer 
admitted  by  any  body  to  exist ;  those  anatomists  probably  allowed 
■*'  themselves  to  be  deceived  by  the  primitive  and  natural  granulations 
of  the  chorion.  Notwithstanding  the  assertions  of  Warthon,  Cruik- 
shank,  Mascagni,  Wrisberg,  Micha^lis,  and  Schrceger,  it  is  now 
pretty  generally  agreed  to  deny  the  existence  of  lymphatic  vessels 
in  the  after-birth.  The  same  is  the  case  as  to  the  nerves  which 
Verheyen,  MM.  Ribes,  Home,  and  Bauer  tell  us  they  have  seen. 

477.  However,  Dr  Lauth  has  recently  published  a  work  tending 
to  prove  that  a  great  number  of  lymphatic  filaments  of  a  peculiar 
kind  pass  from  the  placenta  to  the  uterus.  It  is  true  that  when  we 
carefully  separate  the  ovum  from  the  womb  we  perceive  an  infinite 
number  of  small  whitish  threads,  extremely  easy  to  break  ;  but  it  is 
also  certain  that  similar  threads  arc  to  be  seen  when  separating  the 
caduca  from  the  surfaces  which  it  lines,  the  amnios  from  the  chorion, 
&c.,  that  these  are  merely  gelatinous  or  mucous  tracts,  but  not 
vessels,  nerves,  nor  even  cellular  filaments. 

478.  The  blood  vessels  thci-eforc  compose  the  fundamental  ele- 
ment of  the  placenta  ;  these  vessels  are  but  expansions  or  ramifi- 
cations of  those  of  the  cord,  and  like  those  of  the  navel  string 
arc  not  developed  until  after  the  third  week,  and  then  by  intus- 
susception and  gradually. 

Previously  to  this  period,  the  villous  matter  of  the  chorion  does 
not  contain  any  of  them,  and  this  villous  portion  may  until  then  be 
compared  to  the  hairy  part  of  the  roots  of  plants.  It  contains,  in- 
deed, spongiolcs,  radicles,  and  articulated  filaments  analogous  to 
those  described  by  MM.  De  CandoUc,  Correa  and  Dutrochet ;  if  it 


PLACENTA.  1S3 

do^s  take  up  any  fluids  from  the  surrounding  parts,  it  must  imbibe 
or  absorb  them  after  the  manner  of  vegetables.  At  a  later  period, 
vascular  channels  are  formed,  as  happens  in  new  tissues.  Being  at 
first  much  smaller  than  the  radicles  with  which  they  are  surrounded, 
they  do  not  seem  to  extend  throughout  the  whole  length  of  the 
chorion,  even  at  a  pretty  advanced  period  of  their  growth.  I  have 
injected  them  with  coloured  alcohol,  size,  spirits  of  turpentine,  &c. 
at  the  third  and  fourth  months,  and  afterwards  examined  them  with 
the  microscope,  and  although  the  injection  had  passed  into  vessels 
finer  than  those  of  the  choroid,  it  always  stopped  at  a  considerable 
distance  from  the  extremities  of  the  villous  branches.  This  por- 
tion, which  cannot  be  injected,  has  always  appeared  to  me  to  be, 
like  the  primitive  tomentum,  unprovided  with  any  central  channel,  to 
be  of  a  spongy  nature,  and  to  absorb  only  by  means  of  imbibition. 

The  bands  and  solid  white  filaments  that  are  found  in  the  pla- 
centa even  after  delivery,  and  which  are  attached  to  thq  chorion, 
are  not,  as  some  contemporary  authors  too  confidently  assert,  oblite- 
rated vessels  :  they  never  were  hollow,  and  remain  solid,  as  they 
were  at  the  commencement.  They  are  similar  to  those  which  con- 
nect the  reflected  portion  of  the  anhistous  membrane  to  the  villous 
coat,  and  belong  to  some  primitive  branches  of  the  villous  coat  of 
the  ovule,  in  which  no  vessels  were  developed*. 

Do  the  venous  capillaries  appear  before  the  arterial  capillary  ves- 
sels ?  Is  the  contrary  the  case  ?  The  assertions  of  Beclard,  of 
Meckel,  of  Lobstein,  &c.,  concerning  this  point  in  anatomy,  are  any 
thing  but  conclusive  :  having  always  met  with  arterial  at  the  same 
time  with  venous  branches,  I  am  disposed  to  believe  that  both  these 
kinds  of  canals  appear  together ;  and  how  could  it  be  otherwise  ? 
If  the  blood  enters  in  one,  must  it  not  return  by  the  other  kind  of 
vessels? 

Each  vascular  branch,  in  separating  from  the  outer  surface  of  the 
chorion,  is  composed  of  a  single  artery  and  a  single  vein,  which  arc 
already  twisted  in  a  spiral  manner  ;  the  trunk  soon  divides  into  two 
branches  of  each  sort,  and  these  again  into  two  others,  so  that  these 
dycotomic  ramifications  go  on  almost  ad  infinitum :  being  pressed 


*  I  maiutained  this  opinion  in  the  year  1823  (Archiv.  Gen.  de  Med.  1824), 
and  have  ever  since  continued  to  inculcate  it  in  my  public  lectures  on  midwifery. 
I  am,  therefore,  not  without  reason  surprised  to  see  MM.  Breschet  and  RaspaiT, 
who  have  confirmed  it  by  some  recent  microscopical  experiments,  endeavouring 
to  attribute  it  to  themselves,  or  lefev  it  to  Carus,  who  never  spoke  of  it  before  the 
year  1827;  M.  Breschet  should  have  recollected,  however,  that  while  examining 
the  granulations  of  the  chorion  with  a  lens  in  iiis  study  in  February  1824,  we 
discussed  this  subject,  and  that  ho  was  not  then  of  my  way  of  thinking. 


184  APPENDAGES  OF  THE  FCETUS. 

together  and  united  to  each  other  by  means  of  the  fibrous  layer, 
these  divisions  and  subdivisions  constitute  a  lobe,  or  cotyledon  of  the 
placenta.  In  ruminating  animals,  particularly  in  the  cow,  these 
lobes  being  very  remotely  separated  from  each  other,  form  so  many 
distinct  placentae. 

All  the  vessels  of  one  lobe  communicate  with  each  other ;  but  the 
experiments  of  Wrisberg,  which  I  have  repeated,  prove  that  they  do 
not  in  general  communicate  with  those  of  a  neighbouring  lobe. 

479.  When  any  of  these  lobes  separate  from  the  others,  and  are 
at  some  distance  from  the  placental  disc,  they  form  a  small  distinct 
placenta,  and  this  has  assuredly  been  the  reason  which  has  on  more 
than  one  occasion  led  to  the  belief  that  there  were  two  placentae  to 
one  single  fcetus.  Each  one  unites  to  those  about  it,  as  the  different 
lobules  of  the  same  cotyledon  are  united  among  themselves,  and 
their  adhesion,  which  takes  place  in  the  third  month,  may  easily  be 
broken  up  at  full  term :  being  thus  disposed,  they  constitute  the 
parenchyma  of  the  placenta,  so  that  this  parenchyma  is  entirely  com- 
posed of  vessels,  of  solid  filaments,  of  granulations,  and  a  fibrinous 
matter  which  serves  as  a  common  bond  of  union  for  them,  but  not 
of  any  cellular  basis  analogous  to  that  of  other  organs. 

480.  MM.  Dubois  and  Biancini  state  that  they  have  injected  the 
arteries,  and  probably  the  veins  also,  which  pass  from  the  uterus  to 
the  placenta,  and  vice  versa ;  Reuss  has  given  a  drawing  of  them, 
and  Albinus  had  already  noticed  them ;  I  have  vainly  sought  for 
these  tUero-placental  vessels  in  a  great  number  of  subjects,  and  the 
condition  of  the  parts  has  convinced  me  that  if  they  do  sometimes 
exist,  they  are  far  more  frequently  wanting.  I  can  assure  the  reader 
that  whenever  I  have  examined  the  ovum  in  the  uterus  after  the 
third  month,  its  surface,  as  well  as  that  of  the  womb,  was  smooth 
throughout  its  whole  extent,  and  that  not  a  single  vessel  served  to 
maintain  the  connexion  between  these  two  parts.  Might  not  the 
learned  authors  whom  I  have  mentioned  have  been  deceived  by  some 
anomaly,  some  patliological  state,  or  some  false  appearances  ?  Could 
I  have  been  mistaken  myself?  Time  and  additional  facts  alone  can 
resolve  this  question,  which  1  leave  for  the  curious. 

Development.  Anatomists  have  all  treated  of  the  formation  of 
the  placenta  ;  but  only  a  few  of  them  have  studied  it  methodically, 
even  since  Hunter  made  us  better  acquainted  with  the  nature  of  the 
decidua.  Jt  has  been  said,  that  when  the  ovule  reaches  the  womb 
there  appear  on  its  external  surface  certain  branching  villi  which 
penetrate  through  the  anliistous  membrane  so  as  to  come  in  con- 
tract with  tho  womb,  and  that  the  placenta  is  formed  in  this  man- 
ner ;  that  those  villi,  at  first  rcg«larly  disseminated  over  the  entire 


PLACENTA.  185 

surface  of  the  ovule,  soon  begin  to  collect  in  groups  and  to  assemble 
together  at  one  point,  but  becomes  every  where  else  smooth  and 
transparent ;  that  the  placenta  cannot  be  distinguished  until  after 
the  end  of  the  second  month  ;  that  it  then  covers  two-thirds  or  at 
least  one  half  of  the  ovum,  and  that  its  proportional  breadth  becomes 
less  and  less  as  the  pregnancy  advances,  &.c. 

481.  The  following  is  an  account  of  what  we  do  observe :  after 
gliding  betwixt  the  inner  surface  of  the  womb  and  the  caduca,  and 
becoming  attached  to  the  organ  destined  to  contain  it  until  the  end 
of  pregnancy,  one  half  of  the  villous  vesicle  is  necessarily  in  contact 
with  it,  while  the  other  half  pushes  away  the  anhistous  membrane. 
From  this  moment  one  disc  of  the  ovule  is  left  in  direct  contact 
with  the  living  surface,  without  the  interposition  of  the  deciduous 
membrane,  and  here  the  placenta  is  developed  :  this  is  the  only  spot 
in  the  womb  at  which  the  germ  can  take  up  the  principles  of  its 
nutrition,  resembling  in  this  respect  a  vegetable  inclosed  in  a  vessel, 
and  having  no  communication  with  the  earth  save  by  a  small  open- 
ing at  the  bottom. 

It  is  then  evident  that  the  placenta  in  some  sort  begins  to  grow 
as  soon  as  the  ovule  reaches  the  uterus,  and  not  merely  after  the 
two  first  months  of  gestation  ;  that  the  relative  dimensions  of  it  and 
the  whole  ovum  are  about  the  same  from  first  to  last ;  and  that 
it  is  consequently  incorrect  to  say  that  it  covers  more  than  one 
half  of  the  chorion  at  the  second  month,  but  at  a  later  period  only 
a  third,  a  fourth,  &c.  I  have  reason  to  believe  that  it  constantly 
augments  in  the  same  proportion  as  the  surface  of  the  womb  with 
which  it  is  in  immediate  contact ;  so  that  its  width  at  birth  depends 
upon  the  size  of  the  uterus  or  the  dimensions  of  the  point  left  ex- 
posed by  the  decidua  at  the  commencement  of  gestation. 

482.  It  is  well  known  that  the  placenta  may  be  attached  either 
to  the  fundus,  the  front,  the  back  or  sides,  and  sometimes  to  the 
neck  of  the  uterus  ;  but  hitherto  the  cause  of  these  anomalies  has 
not  often  been  inquired  into.  Those  who  say  that  it  attaches  itself 
to  the  most  vascular  part  of  the  uterus,  make  an  assertion  that  is 
void  of  sense  ;  for,  admitting  that  the  ovule  is  at  first  entirely  con- 
cealed in  the  centre  of  the  decidua,  as  several  authors  have  stated, 
and  still  continue  to  assert,  who  is  to  tell  the  villi  that  the  womb  is 
more  favourably  disposed  for  their  reception  in  one  place  than  in 
another  ?  Since  observation  proves  that  the  villi  at  first  cover  the 
whole  vesicle,  instead  of  growing  on  one  portion  of  it,  why  should 
not  the  placenta  occupy  more  or  less  regularly  the  whole  superficies 
of  the  ovum  instead  of  covering  only  one-fifth  of  it  ? 

Y 


186  '  '  APPENDAGES  OF  THE  FCETUS. 

Had  Osiander,  Stein,  and  some  other  writers,  reflected  more 
carefully  upon  the  subject,  they  doubtless  would  not  have  advanced  the 
opinion  that  the  point  of  insertion  of  the  placenta  depends  upon  Ihe 
specific  weight  of  the  fecundated  ovum,  and  consequently,  on  the  atti- 
tude assumed  by  the  woman  immediately  after  impregnation.  Indeed, 
two  remarks  suffice  to  overthrow  this  system:  1.  As  the  vivified 
ovule  does  not  leave  the  tube  for  eight  days,  it  is  manifest  that  until 
then,  the  attitude  of  the  woman  is  a  matter  of  indifference  as  to  the 
point  in  question  ;  2.  Be  the  time  what  it  may  that  is  considered 
necessary  for  the  germ  to  pass  from  the  ovary  to  the  womb,  it  is 
clear  that  it  will  find  the  woman  on  foot  more  frequently  than  in  any 
other  posture,  and  if  the  idea  of  Osiander  were  correct,  that  the 
implantation  of  the  placenta  over  the  cervix,  instead  of  being  very 
rare,  ought  on  the  contrary  to  be  the  commonest  of  all. 

483.  I  think  I  have  discovered  a  much  more  natural  explanation 
of  this  phenomenon,  and  shall  venture  to  submit  it  to  the  examina- 
tion of  naturalists :  upon  entering  the  womb,  the  ovule  necessarily 
meets  with  the  anhistous  sac,  and  can  proceed  no  farther  without 
detaching  it ;  now,  if  the  adhesion  of  this  sac  is  the  same  throughout, 
the  vesicle  follows  its  original  direction,  glides  along  the  fundus  of 
the  womb,  which,  with  the  assistance  of  the  decidua,  seems  to  pro- 
long the  channel  of  the  tube  to  that  of  the  opposite  one,  or  else  it 
stops  as  soon  as  it  issues  from  the  tube,  and  then  the  placenta  at- 
taches itself  to  one  of  the  angles  of  the  uterus.  If  the  adhesion  is 
stronger  above  than  it  is  below,  we  may  conceive  that  the  ovum  will . 
descend  more  or  less  towards  the  cervix  ;  if  the  adhesion  be  strongest 
in  front,  it  will  be  directed  backwards,  and  so  of  the  other  points. 
This  hypothesis  is  further  confirmed  by  direct  observation  ;  of  thirty- 
four  women  who  died  while  pregnant,  or  soon  after  delivery,  at  the 
Hospital  de  Perfectionnement,  I  found  upon  examining  the  parts,  that 
the  centre  of  the  placenta  corresponded  to  the  orifice  of  the  tube  in 
twenty  cases,  it  was  in  front  of  it  in  three  cases,  behind  it  in  two, 
below  it  in  three,  and  in  six  cases  only,  towards  the  front  of  the 
uterus. 

The  mode  of  union  betwixt  the  placenta  and  the  womb  is  another 
point  that  has  occupied  much  of  the  attention  of  physiologists : 
Noorthwyck,  Astruc,  Haller,  Mery,  and  Baudelocque,  thought  that 
the  large  venous  trunks  of  the  womb  were  uninterruptedly  conti- 
nuous with  those  of  the  placenta. 

Warthon,  Rcuss  and  a  great  many  of  the  moderns  suppose  that 
the  part  of  the  womb  which  is  in  contact  with  the  ovum  at  the  com- 
mencement of  gestation  becomes  fungous  ;   that  these  fungosities, 


PLACENTA.  187 

which  constitute  the  uterine  placenta,  intermingle  and  unite  with 
those  of  the  chorion,  from  which  arises  an  intimate  adherence,  which 
the  womb  must  tear  off  before  it  can  expel  the  after-birth. 

It  even  appears  that  Professor  Dubois  argues  from  this  rupture 
that  the  milk  fever  is  really  a  traumatic  fever. 

According  to  Stein  the  lobes  of  the  placenta  are  impressed  into 
the  womb  like  a  seal  into  soft  sealing-wax,  and  the  ramifications  of 
its  vessels  are  implanted  into  the  largest  vessels  of  the  womb,  pretty 
much  as  the  roots  of  a  ^rub  are  implanted  into  the  earth.  Asdru- 
bali  thinks  that  the  placenta  adheres  to  the  womb  in  the  same  man- 
ner as  the  pulp  of  a  peach  clings  to  the  stone.  Leroux  maintained 
that  it  is  in  the  same  way  as  a  leech  attaches  itself  to  the  skin  ; 
others  have  said  that  it  is  like  the  graft  of  a  tree,  that  it  is  effected 
by  means  of  an  accidental  cellular  tissue,  of  peculiar  vessels,  fee.  &c. 

484.  It  appears  to  me  that  what  I  have  said  above  concerning  the 
structure  of  the  external  surface  of  the  placenta,  proves  that  none  of 
these  hypotheses  are  rigorously  correct.  I  may  repeat  with  Ma- 
dame Boivin,  that  in  several  women  who  died  whilst  pregnant,  the 
membrane  which  covers  and  unites  the  lobes  of  the  placenta  ap- 
peared to  me  to  be  the  only  bond  between  it  and  the  womb.  I  have 
remarked,  further,  that  the  adherence  of  the  ovum  was  the  same 
every  where,  that  it  may  be  destroyed  with  the  handle  of  a  scalpel 
without  the  least  difficulty,  and  without  rupturing  any  thing  save 
some  mucous  tracts  like  those  found  between  the  amnios  and  cho- 
rion, between  the  croup  membrane  and  the  membrane  that  secreted 
it.  The  error  of  the  authors  upon  this  subject  manifestly  depends 
upon  their  having  but  few  opportunities  of  examining  the  ovum  in 
the  womb,  and  especially  upon  this :  viz.  that  in  women  who  die  a 
few  days  after  delivery,  the  internal  surface  of  the  last  named  organ 
remains  swelled  and  fungus-like  at  the  part  that  corresponded  to 
the  placenta. 

485.  Double  ova.  After  what  I  have  said  heretofore  of  the  dif- 
ferent parts  of  the  ovum,  I  may  dispense  with  entering  into  any  con- 
siderable details  relative  to  double  pregnancy.  If  two  ovules  reach 
the  womb,  each  by  a  different  tube,  or  if  they  attach  themselves  to 
it  at  a  certain  distance  from  each  other,  they  will  each  have  a  dis- 
tinct placenta,  chorion  and  amnios,  and  sometimes  even  an  epicho- 
rion,  until  a  certain  stage  of  the  gestation.  If,  on  the  contrary,  they 
had  already  contracted  some  adhesion  together  previously  to  leaving 
the  Fallopian  tube,  or  if  they  happen  to  remain  very  near  each  other 
in  the  uterus,  it  may  be  that  they  shall  be  enclosed  in  one  single  leaf 
of  the  decidua,  and  that  their  villi,  as  well  as  their  chorion,  shall  be 
early  confounded  together.     In  this  case  it  may  be  that  the  septum 


188  APPENDAGES  OF  THE  F(ETUS. 

formed  by  their  conjunction,  shall  give  way,  and  cause  the  two 
fostuses  to  be  found  enclosed  at  birth  in  one  single  bag  of  membranes, 
numerous  instances  of  which  are  related  in  the  scientific  collections, 
and  of  which  one  of  the  most  authentic  has  been  recently  laid  before 
the  public  by  Madame  Boivin.  Nevertheless,  such  a  circumstance 
is  of  very  rare  occurrence,  for  in  double  after-births,  I  have  always 
succeeded  in  tracing  the  chorion  and  amnios  to  the  intermediate 
septum,  where  the  two  membranes  were  more  or  less  promptly  con- 
founded, and  in  a  more  or  less  intimate  degree.  In  general,  the 
vessels  of  the  two  placentas  do  not  communicate  with  each  other, 
any  more  than  the  vessels  of  the  different  lobes  of  the  same  placenta ; 
but  it  is  easily  conceived  that  the  contrary  may  take  place  some- 
times, as  seems  to  be  demonstrated  by  facts  carefully  examined. 


ARTICLE  II. 
Of  the  Foetus. 

486.  The  ancients  retained  the  name  yorm  seed  for  the  product 
of  conception  for  the  first  six  days.  During  the  next  nine  days  they 
called  it  »u)if*<t^  then  embryo  for  twelve  days,  after  which  they  made 
use  of  the  term  ojricT/oy,  to  designate  the  fcetus  until  the  forty-fifth  day, 
and  these  four  supposed  periods  were  characterized  by  them  in  the 
two  following  verses ; 

Sex  in  lacte  dies,  ter  sunt  In  sanguine  tern!. 
Bis  seni  carnem,  ter  seni  membra  figurant. 

At  present  it  is  generally  agreed  to  give  to  the  germ,  when  with- 
out its  membranes,  the  name  of  embryo,  until  the  third  month  of 
pregnancy  ;  or  according  to  some,  until  its  several  parts  can  be  dis- 
tinguished from  each  other ;  it  is  afterwards  called  fxtus  as  long  as 
it  remains  in  the  womb,  and  the  term  child  is  not  applied  to  it  until 
after  its  birth.  Although  this  division  is  entirely  arbitrary  and  difli- 
cult  to  justify,  I  feel  bound  partially  to  conform  to  it  in  this  work. 

SECTION  1. 
Development  of  the  Embryo,  and  of  the  Fcetus. 

487.  The  period  at  which  the  embryo  first  appears  in  the  uterus 
is  still  enveloped  in  darkness,  and  vain  attempts  have  for  twenty  cen- 


EMBRYO.  189 

turies  been  made  to  penetrate  the  mystery  with  which  it  is  surrounded. 
At  the  sixth  day,  says  Hippocrates,  the  semen  is  changed  into  a 
transparent  bubble,  in  which  a  very  small  point  appears,  which  is 
probably  the  navel.  According  to  Hauler  and  most  of  his  pupils,  the 
embryo  is  not  perceptible  until  the  fifteenth  or  twentieth  day.  Of 
those  authors  who,  with  the  ancients,  suppose  that  fecundation  takes 
place  in  the  womb,  a  part  maintain  that  the  embryo  is  formed  first, 
and  the  membranes  afterwards  ;  others,  with  Hippocrates,  Mauper- 
tuis,  de  Bufl^on,  &c.,  teach  that  the  membranes,  on  the  contrary, 
appear  first ;  yet  no  one  has  succeeded  in  showing  on  what  day  the 
embryo  begins  to  be  visible.  Again,  the  ovarists  and  animalculists, 
are  in  the  first  place  far  from  agreeing  with  each  other ;  and  we  cannot 
perceive  that  the  proofs  they  adduce  in  support  of  their  assertions  are 
much  more  satisfactory  than  those  of  the  partisans  of  the  ancient 
hypothesis.  Finally,  the  opinion  of  Haller,  which  had  been  generally 
adopted  as  the  most  probable,  has  been  lately  very  much  shaken  by 
the  publication  of  a  fact  which  has  been  supposed  to  be  of  a  nature  to 
dissipate  every  uncertainty ;  I  allude  to  the  case  recently  made  public 
by  Messieurs  Home  and  Bauer  at  London. 

However,  the  sensation  produced  in  the  scientific  world  by  this 
case,  seems  to  me  as  extraordinary  as  it  is  difficult  of  comprehension, 
and  can  only  be  explained  by  the  urgent  desire  that  is  felt  to  escape 
from  the  uncertainty  that  still  prevails  in  science  upon  this  interest- 
ing point  in  natural  history. 

What !  shall  we  dare  to  conclude,  because  a  servant  girl  returns 
sick  to  her  master's  house,  and  eight  days  afterwards  dies  with  con- 
vulsions and  delirium,  that  she  became  pregnant  the  day  she  went 
out  ?  Because  the  sexual  organs  of  a  woman  whose  menses  are  sup- 
pressed are  not  in  a  natural  state,  it  is  thought  possible  to  assert 
that  she  was  pregnant !  Further,  even  admitting  this  last  point,  which 
certainly  proves  nothing,  what  right  have  vre  to  maintain  that  the 
corpuscule  which  was  found  in  the  midst  of  a  mass  of  coagulable 
lymph,  was  a  germ  rather  than  any  thing  else  ?  Let  those  who  feel 
interested  in  this  subject,  take  the  trouble  to  examine  Mr  Home's 
note  and  the  accompanying  plate,  (PIHlos.  Trans.  1817,  page  252.) 
let  them  weigh  all  the  circumstances,  and  then  say  whether  such 
men  as  Beclard  and  M.  F.  Meckel  ought  to  modify  their  opinions 
upon  suoh  a  case. 

488.  The  experiments  of  R.  de  Graaf  and  Nuck,  repeated  by 
Duverney,  Haighton  and  Cruikshank,  if  they  are  accurate,  have  long 
since  demonstrated  that  the  product  of  fecundation  in  animals  is  a 
vesicle,  and  that  this  vesicle  takes  up  some  days  at  least  to  pass 
from  the  ovary  to  the  womb.     It  is  true  we  arc  ignorant  whether 


190  THE  F(ETUS.  ' 

the  time  that  elapses  between  the  vivification  of  the  germ  and  its 
arrival  in  the  womb  is  always  the  same  in  the  same  animal  or 
whether  there  is  any  fixed  and  certain  time  for  the  different  species  • 
but  it  appears  that  this  term  is  three  days  in  rabbits,  and  according 
to  MM.  Prevost  and  Dumas,  who  have  lately  made  numerous  re- 
searches on  the  subject,  that  it  is  from  six  to  seven  days  in  the 
bitch. 

489.  Strato,  as  Macrobius  informs  us,  supposed  that  the  foetus 
does  not  begin  to  assume  the  human  form  until  about  the  thirty- 
fifth  day,  when  it  is  as  large  as  a  bee.  Aristotle  teaches  that  at 
forty  days  the  embryo  is  of  the  size  of  a  large  ant ;  and  that  we 
can  distinguish  its  limbs  and  all  its  parts,  even  the  penis,  if  it  be  a 
male.  It  has  been  stated  by  others,  but  less  correctly,  that  from  the 
fifteenth  to  the  twentieth  day  the  embryo  is  vermiform,  oblong,  or 
tumid  in  the  middle.  M.  Orfila,  in  speaking  of  the  primitive 
state  of  the  foetus,  is  very  wide  of.  the  truth.  The  same  may 
be  said  of  M.  Meckel  when  he  asserts  "  that  the  part  that  first  ap- 
pears corresponds  almo^st  exclusively  to  the  trunk  ;  that  we  only  re- 
mark at  its  upper  part  a  small  projection,  separated  from  the  rest  by 
a  notch,  and  whose  thickness  is  not  near  equal  to  that  of  the  mid- 
dle portion  of  the  body  ;  that  the  embryo  is  almost  entirely  strait, 
&,c."  Ph.  Beclard  by  reproducing  the  ideas  of  the  celebrated 
German  anatomist,  has  fallen  into  the  same  mistake  ;  nor  has  M. 
Adelon  been  more  fortunate  in  admitting  that  the  embryo  exhibits 
no  traces  of  a  head  at  three  weeks,  and  that  the  belly  appears  un- 
der the  form  of  a  conical  projection  resting  on  the  inner  membrane 
of  the  ovum.  Nor  do  I  understand  why  Madame  Boivin  affirms 
that  "  at  the  tenth  day,  the  embryo  is  merely  a  greyish  semi-trans- 
parent flake,  easily  liquefied,  and  of  a  form  difficult  to  determine." 
It  is  also  certain,  that  when  comparing  it  to  a  lettuce  seed,  or 
grain  of  barley,  as  Burton  did,  or  even  to  the  malleus  of  the  ear, 
like  Baudelocque,  they  could  have  had  before  them  only  preterna- 
tural specimens. 

§.  I.  Of  the  embryo  in  gCTieral. 

Previously  to  the  end  of  the  first  week,  there  is  a  striking  resem- 
blance between  the  human  embryo  and  that  of  some  of  the  serpents, 
putting  aside  the  proportional  length.  It  is  a  curved  body,  form- 
ing nearly  a  complete  circle,  which  in  this  state  may  be  two  or 
three  lines  in  diameter,  but  which  if  straight  would  be  at  least  four 
or  five.  It  may  be  compared  to  some  of  the  animalcules  figured 
by  MM.  Prevost  and  Dumas,  particularly  to  the  animalcule  of  the 
dog ;  that  is  to  say,  one  of  its  extremities  is  bulbous  and  rounded, 


EMBRYO.  191 

and  the  other  terminates  in  a  point :  which  gave  rise  to  a  belief  in 
the  existence  of  a  primitive  tail  in  the  human  species.  Being  hol- 
low and  semi-transparent,  this  stock  seems  to  be  filled  with  a  limpid 
fluid,  in  the  centre  of  which  may  be  seen,  even  with  the  naked  eye, 
an  opaque  filament,  of  a  white  or  yellowish  tint,  which  represents  the 
cerebro-spinal  system. 

490.  Numerous  observations  made  on  very  young  embryos  seem 
to  me  to  prove  :  that  the  rachis  is  the  fundamental  part  of  the  body  ; 
that  it  appears  previously  to  any  of  the  other  organs ;  that  for  a 
considerable  time  it  exists  alone  ;  that  its  form  does  not  essentially 
differ  from  that  which  it  possesses  during  the  remainder  of  its  intra- 
uterine life  ;  that  for  twenty  days,  or  a  little  longer,  the  embryo  is 
neither  straight  nor  enlarged  in  the  middle  ;  that  the  head  and  neck 
constitute  at  least  one  half  of  its  total  length  ;  that  the  younger  it 
is  the  more  does  its  curve  approach  to  the  form  of  a  circle  ;  that 
the  appearances  of  its  external  circumference  differ  very  little  at 
first  from  what  they  are  at  a  subsequent  period,  while  its  interior  con- 
tour or  concavity  merits  the  most  serious  attention,  on  account  of 
the  changes  it  must  undergo. 

491.  In  fact,  the  organs  appear  in  succession  upon  this  concave 
surface  ;  at  first  the  different  parts  of  the  face,  then  the  Jimbs,  and 
between  these  latter  the  thoracic  and  abdominal  viscera.  Nothing  is 
so  admirable  as  this  development ;  it  might  be  called  a  real  vegeta- 
tion ;  the  lower  jaw,  the  members,  the  mass  that  is  to  occupy  the 
abdomen  and  the  breast,  increase  and  come  forwards,  like  buds 
springing  from  the  branch  of  a  tree,  or  axile  of  a  plant. 

The  spinal  circle  thus  fills  up  by  degrees ;  the  forehead  becomes 
farther  removed  from  the  coccyx  ;  the  thoracic  and  abdominal  por- 
tions of  the  original  stock  are  forced  to  become  straighter ;  the 
head  remains  constantly  inclined  upon  the  breast,  but  in  such  a  way, 
however,  that  the  chin  at  last  takes  the  situation  previously  oc- 
cupied by  the  forehead.  The  coccyx  does  not  retire  backwards 
until  a  very  late  period  ;  it  is  moved  in  that  direction  by  an  ex- 
tremely simple  mechanism  ;  to  wit,  the  development  of  the  pelvis 
and  lower  extremities. 

492.  From  seeing  that  the  lateral  and  anterior  portions  of  the 
body  do  not  become  manifest  for  a  considerable  length  of  time  af- 
ter the  vertebral  frame,  I  have  more  than  once  been  tempted  to  be- 
lieve, with  MM.  Tiedemann  and  Meckel,  Serres  and  Geoffroy  St 
Hilaire,  that  the  organic  evolution  really  takes  place  from  the  sides 
towards  the  median  line,  and  with  M.  Richerand,  to  say  that  the 
embryo  is  at  first  only  a  groove,  the  edges  of  which  vegetating 
from  behind  forwards,  can  only  unite  by  a  species  of  suture  upon 


192 


THE  F(ETUS. 


the  anterior  median  line.  But  attentive  and  frequently  repeated  ob- 
servation compelled  me  to  abandon  this  hypothesis  ;  in  the  median 
line  of  the  face  and  neck  I  never  could  discover  any  void  ;  I  have 
found  it  to  be  as  completely  closed  at  the  twentieth  as  at  the  six- 
tieth day  ;  nor  have  I  even  seen  the  thoracic  organs  entirely  expos- 
ed, although  the  mass  from  which  they  grow  seems  to  be  covered, 
as  far  as  the  belly  is  concerned,  only  with  a  very  delicate  tissue  ;  the 
parietes  of  the  chest  nevertheless  exhibit  their  natural  appearances 
as  soon  as  they  can  be  discovered. 

§.  11.  Of  the  head,  and  organs  of  the  senses. 

At  the  beginning  the  head  resembles  a  very  long  club  ;  its  subse- 
quent growth  is  proportioned  to  that  of  the  rachis  ;  but  the  appear- 
ance of  the  abdomen  and  thorax  soon  occasion  it  to  lose  a  portion 
of  its  apparently  enormous  size.  As  neither  the  face  nor  chest 
exist  at  first,  there  is  in  fact  no  neck  at  the  commencement  of 
embryo  life.  At  five  weeks  the  face  is  very  distinct  from  the  cra- 
nium, and  the  head,  quite  isolated,  no  longer  resembles  a  mere  pyri- 
form  enlargement ;  and  its  cranial  portion  also  permits  us,  most 
commonly,  to  discern  in  the  vesicle  which  it  constitutes,  the  general 
arrangement  of  the  encephalon.  Its  facial  portion  is  already  quite 
opaque. 

493.  The  mouth.  The  mouth  is  the  first  organ  of  the  senses  that 
can  be  perceived :  I  have  found  it  in  the  youngest  embryos  that  have 
fallen  under  my  notice  ;  consequently,  it  exists  at  the  twentieth  day, 
and  then  forms  a  very  large,  elliptical  or  triangular  opening  ;  as  the 
upper  jaw  is  very  projecting,  while  the  lower  one,  on  the  contrary, 
is  very  short,  it  follows  that  the  mouth  of  a  human  embryo  bears  a 
striking  resemblance  to  that  of  a  young  snake.  Anatomists  have 
never  altered  the  ideas  they  had  formed  as  to  the  manner  in  which 
the  lower  lip  is  constituted  ;  they  have  all  supposed  that  it  was  pri- 
mitively composed  of  two  lateral  portions,  which  at  length  united  at 
a  middle  line,  like  the  two  bony  pieces  which  support  it ;  but  it  is 
not  so  with  the  upper  lip.  As  long  as  it  was  thought  that  the  upper 
jaw  consisted  only  of  two  pieces,  it  was  supposed  that  the  corres- 
ponding lip  must  be  also  formed  of  only  two  pieces.  But  since  an 
intermaxillary  bone  has  been  discovered  in  the  human  skeleton,  it  is 
generally  agreed  that  the  lip  is  formed  of  tliree  portions,  one  middle 
tubercle  and  two  lateral  parts,  which  by  their  union  give  birth  to 
the  two  columns,  or  naso-labial  ridges.  This  is  the  theory  upon 
which  modern  writers  account  for  the  formation  of  simple  or  double 
hare-lip,  which,  according  to  them,  should  never  be  met  with  exactly 
in  the  middle  of  the  lip  ;  finally,  still  improving  upon  these  divisions, 
which  arc  already  too  numerous,  it  has  recently  been  asserted  that 


THE  F(ETUS,  193 

the  upper  lip  is  developed  from  four  separate  points.  I  think  I  may 
venture  to  affirm,  that  such  ideas  could  only  have  arisen  from  obser- 
vations not  attentively  made,  or  too  rarely  repeated.  In  the  course 
of  the  period  I  am  now  examining,  the  lower  lip  begins  to  be  per- 
ceptible ;  the  chin  causes  the  middle  of  it  to  project  forwards  ;  but 
its  loose  edge,  which  is  pretty  thin,  is  not  interrupted  by  any  slit, 
and  represents  a  very  regular  semicircle ;  it  is  longer,  and  has  a 
deeper  curve  than  the  other  ;  but  in  embryos  of  six  weeks,  and  in 
some  a  little  above  twenty  days -old,  1  have  found  the  edges  of  both 
lips  perfectly  formed,  and  without  any  division  whatever. 

494.  The  nose.  It  is  incorrect  to  say  that  the  organ  of  smell 
cannot  be  recognized  until  towards  the  sixth  or  eighth  week.  At 
thirty  days  it  is  often  in  our  power  to  distinguish  its  anterior  open- 
ings, which  are  round,  situated  immediately  above  the  mouth, 
look  directly  forwards,  and  resemble  two  blackish  spots.  However, 
neither  the  nasal  protuberance  properly  so  called,  nor  the  naso- 
palatine vault  exist  as  yet.  It  is  true,  nevertheless,  that,  in  several 
embryos  of  from  five  to  seven  weeks,  the  orifices  of  the  nose  were 
not  very  evident  to  me,  while  a  very  decided  eminence  already 
occupied  its  place. 

495.  The  eyes.  The  organs  of  vision  appear  at  the  same  time 
with  the  mouth,  if  not  earlier.  I  have  distinguished  them  in  em- 
bryos not  exceeding  four  lines  in  length,  and  they  are  never  sought 
for  in  vain  in  the  course  of  the  fourth  week.  At  this  period  its 
structure  is  surprisingly  simple,  if  compared  to  what  it  must  become 
at  a  later  period.  Without  lids,  canthi,  or  lacrymal  apparatus,  re- 
sembling a  circular  disc  half  a  line  in  diameter,  and  shghtly  convex, 
the  visual  bulb  is  separated  from  the  surface  only  by  a  slight,  super- 
ficial, and  very  ftarrow  groove,  which  can  only  be  found  by  searching 
for  it  with  a  needle.  Two  spots  seem  to  constitute  it  entirely  :  one 
of  a  yellowish  white  composes  the  centre  ;  the  other,  of  a  black 
colour,  exhibits  the  appearance  of  a  circle,  on  the  one  hand  en- 
closing the  former,  and  on  the  other  continuous  with  the  integuments. 
The  central  spot  is  at  first  much  larger  than  the  black  circle  that 
surrounds  it,  but  in  general  the  latter  seems  to  me  to  exceed  the 
former  in  size  towards  the  end  of  the  sixth  week.  The  whole  in- 
dubitably represents  the  sclerotica,  and  the  transparent  cornea, 
which  is  still  completely  opaque,  and  seems  not  to  differ  from  the 
nails,  except  in  regard  to  colour.  It  might  in  fact  be  called  a  por- 
tion of  skin  or  epidermis  that  becomes  modified  according  to  the 
wants  of  the  system.  Far  from  being  directed  in  front  during  this 
period,  the  eyes  are,  on  the  contrary,  turned  very  much  to  the  sides 
of  the  head,  as  is  the  case  in  a  majority  of  quadrupeds.     I  have  no 

Z 


194  1HE  FOETUS. 

need  to  say  that  they  are  neither  separated  nor  surrounded  by  any 
projecting  portion  of  the  face,  for  the  orbitar  arches  and  root  of  the 
nose  are  not  as  yet  apparent. 

496.  The  ears.  The  ear  also  appears  very  early  ;  it  is  distin- 
guishable on  the  thirtieth  day  at  the  latest,  and  undergoes  no  re- 
markable changes  until  the  sixth  or  seventh  week  ;  at  first  it  looks 
like  the  simple  orifice  of  a  cutaneous  follicle,  or  a  shallow  and  nar- 
row pyramidal  depression  ;  some  days  later  it  might  be  mistaken  at 
a  first  glance  for  a  leech  bite,  excenting  that  it  has  four  angles  in- 
stead of  only  three.  There  is  no  trace  nor  rudiment  of  the  auricula  ; 
its  opening  is  on  a  level  with  the  skin,  and  like  the  eye,  the  or- 
gan of  hearing  appears  to  be  only  a  modification  of  a  point  on 
the  tegumentary  surface  ;  from  the  fifth  to  the  sixth  week  the  inner 
angles  of  this  crucial  or  rhomboidal  depression  begin  to  rise  above 
the  level  of  the  skin ;  the  tragus  appears  first,  then  the  anti-tragus, 
and  after  that  the  rest  of  the  concha.  All  these  parts  grow  by  a 
sort  of  excentric  vegetation  ;  and  it  is  some  time  before  they  incline 
towards  the  head,  and  dispose  themselves  in  regular  order. 

§.  III.  Of  the  members,  and  lower  parts  of  the  trunk. 

I  have  in  vain  endeavoured  to  learn  which  of  the  members  ap- 
pears first.  Whenever  I  have  been  able  to  distinguish  the  thoracic 
appendages,  the  pelvic  extremities  were  equally  visible.  Neither 
have  I  found  in  their  dimensions  such  great  disproportions  as  are 
mentioned  by  authors  :  at  first  there  is  only  a  small  interval  be- 
twixt them  ;  the  former  emerge  from  the  anterior  part  of  the  lateral 
bands  of  the  spinal  trunk,  at  about  an  equal  distance  from  the 
top  of  the  head  and  the  point  of  the  coccyx,  supposing  the  embryo 
to  be  straightened  out ;  the  latter  are  seen  about  on«  line  above  the 
coccyx,  which  is  curved  from  behind  forwards,  and  concealed  as  it 
were  in  the  space  between  them. 

As  long  as  none  of  the  abdominal  or  thoracic  organs  are  yet  de- 
veloped, they  arc  not  so  near  to  the  convex  as  to  the  concave  sur- 
face of  the  spinal  circle  ;  but  the  roots  of  them  seem  to  be  fartlier 
backwards,  as  we  pass  farther  and  farther  beyond  the  fourth  week. 

The  hand  is  seen  first  in  the  shape  of  a  sort  of  pallet  with  a  loose 
and  thin  but  undivided  edge  ;  the  foot  does  not  sensibly  differ  from 
it ;  these  two  parts  have  a  slightly  concave  surface,  which  is  turned 
towards  the  median  line ;  their  edges,  which  are  somewhat  inclined 
towards  each  other,  look  chiefiy  in  a  forward  direction. 

497.  Fronj  tlic  thirtieth  to  the  fortieth  day  the  fore-arm  and  the  leg 
are  visible,  and  the  points  of  the  fingers  begin  to  emerge.  At  forty- 
five  or  fifty  days  the  elbow  and  arm  bcgia  to  detach  themselves  from 


THE  FCETUS.  I95 

the  breast  to  which  they  had  been  befot-e  attached  by  means  of  a  mem- 
brane. The  heel  and  knee  also  become  evident ;  nevertheless,  the 
thigh  appears  very  short,  as  well  as  the  arm,  which  doubtless  depends 
upon  its  not  being  as  yet  completely  detached  from  the  sides  of  the  ab- 
domen. All  the  fingers  are  very  distinct,  and  the  gelatinous  substance 
which  unites  their  base  no  longer  extends  as  far  as  their  ends  ;  the 
foot  ceases  to  resemble  the  hand  ;  the  toes  are  arranged  differently 
from  the  fingers  ;  in  one  word,  these  two  organs  exhibit  nearly  the 
same  characteristic  appearances  they  are  to  have  at  birth.  It  is 
manifest  that  one  is  designed  for  the  purpose  of  standing,  and  the 
other  to  be  used  for  the  prehension  of  objects.  This  peculiarity  alone 
might  serve  completely  to  expose  the  absurdity  of  those  sophists 
who  have  insisted  that  the  primitive  mode  of  walking,  in  man,  was 
similar  to  that  of  brutes. 

498.  Coccyx  and.  genitals.  From  the  foregoing  it  will  have 
been  seen,  that  during  the  three  first  weeks  the  trunk  terminates  by 
a  vermiform  extremity,  and  this  sort  of  sacro-coccygeal  tail,  which 
is  bent  very  much  forward,  becomes  straighter  as  its  cavity  becomes 
more  filled  up.  I  ought  here  to  remark,  that  its  edges  soon  become 
continuous  with  the  abdominal  mass,  or  are  concealed  by  the  roots 
of  the  pelvic  extremities.  The  space  between  it,  the  insertion  of 
the  umbilical  cord  and  the  feet,  the  extent  of  which,  until  the  fifth 
or  sixth  week,  scarcely  exceeds  a  line  or  a  line  and  a  half,  retains 
for  a  considerable  time  the  appearance  of  an  excavation  ;  it  is  sub- 
sequently filled  by  the  gradual  growth  of  the  genito-urinary  organs  ; 
and  the  development  or  concentric  increase  of  the  abdominal  pa- 
rietes  and  sides  of  the  coccyx  and  sacrum  at  last  complete  it. 

499.  Towards  the  fortieth  or  forty-fifth  day  a  black  point  is  dis- 
tinguishable in  front  of  the  coccyx,  and  indicates  the  situation  of  the 
anus  ;  a  little  more  towards  the  umbilicus  may  be  seen  a  conical 
tubercle,  with  a  groove  on  its  inferior  part,  constituting  the  rudi- 
ment of  the  clitoris,  or  penis,  according  to  the  sex  of  the  foetus.  A 
slit  which  is  of  sometimes  greater  and  sometimes  less  breadth  and 
depth  extends  from  one  of  these  points  to  the  other.  In  several  in- 
stances, however,  I  have  thought  that  the  intervening  space  in  well 
formed  embryos  was  smooth  ;  so  that,  up  to  this  period,  there  is 
nothing  to  point  out  the  difference  between  the  sexes  :  we  are 
tempted  to  suppose  that  every  foetus  belongs  to  the  male  sex,  for 
there  are  in  fact  neither  labia  nor  scrotum,  and  the  sub-pubic  pro- 
longation is  alike  in  all  specimens. 

500.  The  umbilicus.  Properly  speaking,  there  is  no  navel  until 
the  thirtieth  or  fortieth  day,  and  the  cord  merely  proceeds  to  be 
lost  beneath  the  visceral  mass  of  the  abdomen.     However,  the 


196  THE  FCETUS. 

parietes  of  the  abdomen,  gradually  increasing  towards  the  otnphalo- 
placental  stem,  soon  afterwards  give  birth  to  it. 

601.  After  the  sixth  week,  or  the  fiftieth  day,  the  organization  of 
the  embryo  becomes  rapidly  perfected.  The  eyes  become  more 
convex  ;  a  very  distinct  palpebral  circle  soon  afterwards  surrounds 
them  ;  the  two  extremes  of  the  vertical  diameter  of  this  circle,  by 
gradually  approaching  each  other,  soon  give  it  the  form  of  an 
ellipse,  and  thenceforth  the  two  angles  of  the  eye  are  observed  to 
exist.  In  nine  or  ten  weeks  at  latest,  the  edges  of  the  eyelids  are 
in  contact,  and  so  closely  in  some  specimens,  that  several  authors 
have  supposed  that  adhesion  had  taken  place  between  them.  Pre- 
viously to  coming  in  contact  they  were  thin  and  sharp  ;  but  their  thick- 
ness now  exceeds  that  of  the  eyelids  themselves ;  they  completely 
cover  the  front  of  the  eye,  but  are  so  transparent  that  its  colour 
may  be  easily  distinguished  through  them.  The  central  spot  before 
mentioned  grows  yellow  and  enlarges  ;  one  is  easily  convinced  that 
it  constitutes  the  cornea,  and  that  its  posterior  surface  is  in  contact 
with  a  substance  of  the  same  colour.  The  blackish  circle  is  also 
enlarged,  and  being  extended  farther  backwards,  is  found  to  belong 
to  the  sclerotica,  and  that  its  tint  depends  upon  the  substance  that 
lines  it  internally. 

502.  The  nose^  particularly,  undergoes  remarkable  alterations  : 
the  profuberance  which  it  forms  above  the  lip,  increasing  by  degrees, 
forces  its  anterior  opening  to  incline  gradually  downwards.  Its  in- 
ternal surface,  which  until  the  fifth  week  composes  a  part  of  the 
buccal  cavity,  begins  in  the  course  of  the  sixth  to  be  separated  from  it. 

503.  The  mouth  does  not  undergo  any  essential  change ;  its 
depth  increases  ;  the  tongue  grows  larger  and  thinner ;  the  lower 
jaw  projects  more,  which  renders  the  anterior  cervical  notch  more 
manifest ;  the  lipa  are  more  distinct,  more  isolated,  but  their  form 
is  the  same. 

604.  The  external  ear^  reduced  to  the  appearance  of  a  leech 
bite,  in  an  embryo  of  four  or  five  weeks,  soon  acquires  its  proper 
characters.  Every  part  of  its  concha  is  unfolded.  After  the  tragus 
and  anti-tragus,  we  observe  the  slit  of  the  helix  to  appear,  and  con- 
sequently tlie  concha.  The  lobule  soon  manifests  itself  as  well  as 
the  rest  of  the  helix,  with  which  it  is  continuous ;  and  lastly,  the 
anti-helix  itself  is  visible  as  early  as  the  seventieth  day.  Although 
all  these  parts  are  formed  behind  the  meatus  auditorius,  the  ear 
nevertheless  seems  to  extend  forwards  during  this  whole  period, 
and  to  approach  much  nearer  to  the  angles  of  the  mouth  and 
eyes. 

505.  The  members  very  early  reach  the  form  ot  their  perfect 


THE  FffiTUS.  197 

state ;  in  eight  or  nine  weeks  the  fingers  are  all  separate,  or  only 
adhere  to  each  other  by  a  transparent  gelatinous  substance  ;  their 
three  phalanges  are  distinguishable,  and  tend  already  to  bend  to- 
wards the  palmar  surface  of  the  hand  ;  the  last  phalanx  exhibits  upon 
its  dorsal  surface  a  spot  which  must  be  considered  as  the  rudiment 
of  the  nail ;  certain  opaque  lines  indicate  the  situations  to  be  occu- 
pied by  the  bones  of  the  metacarpus.  The  proportional  length  of 
the  arm  and  thigh,  as  respects  the  fore-arm  and  leg,  is  no  longer  ex- 
traordinary. The  germ  of  the  shoulder  and  hip  can  not  be  over- 
looked. 

506.  The  coccygeal  point  is  more  completely  concealed  by  the 
pelvic  members,  and  projects  less  than  it  does  a  fortnight  later. 
The  anus  ceases  to  exhibit  the  appearance  of  a  blackish  depressed 
spot ;  at  sixty  days  it  forms  a  small  conical  projection,  not  perforat- 
ed, and  of  a  more  or  less  intense  yellow  colour.  The  genital  tu- 
bercle continues  to  increase  in  length,  and  its  base  is  surrounded  by 
a  very  thick  cushion  ;  at  some  distance  from  its  extremity  is  seen  a 
circular  groove,  which  corresponds  to  the  corona  of  the  glans. 
The  channel  along  its  inferior  surface  is  in  a  great  many  embryos 
entirely  shut,  but  in  some  it  is  still  prolonged  in  the  form  of  a  slit 
to  within  one  lino  of  the  anal  tubercle.  The  development  of  the 
perineum,  of  the  pelvis,  and  hypogastrium,  occasions  the  cord, 
which  in  the  first  period  appeared  to  be  inserted  betwixt  the  roots 
of  the  inferior  extremities  very  near  the  coccyx,  to  remove  to  a 
considerable  distance  from  those  parts,  as  it  approaches  nearer  to 
the  centre  of  the  abdominal  protuberance.  The  circle  of  the  um- 
bilicus ^at  last  unites  so  intimately  with  the  cord  which  passes 
through  it,  that  there  is  no  longer  any  line  of  demarcation  between 
the  teguments  of  the  one  and  the  membranous  sheath  of  the  other. 
Then,  if  as  until  birth,  the  size  of  the  belly  appears  to  be  enormous, 
it  must  be  attributed  in  part  to  the  circumstance  that  the  organs  con- 
tained in  the  pelvis  on  the  one  hand,  and  in  the  thorax  on  the  other, 
do  not  attain  their  perfect  development  until  a  very  late  period. 

507.  Dimensions  of  the  fcBtus  at  different  stages  of  pregnancy. 
As  the  embryo  is  curved  forwards  while  it  remains  loose  in  the 
centre  of  the  ovum,  it  seems  to  me  that  it  ought  always  to  be  placed  in 
this  situation  when  we  go  about  to  measure  its  length.  How  can  we 
otherwise  obtain  determinate  results  ?  If,  during  the  first  six  weeks, 
we  should  attempt  to  straighten  it  out  for  the  purpose  of  measuring 
the  distance  from  the  vertex  to  the  os  coccygis,  the  front  of  the  neck 
and  the  abdomen  would  rarely  fail  to  be  lacerated ;  at  two  months 
the  firmness  of  the  parts  mostly  enables  us  to  avoid  such  an  accident. 


198  THE  FffiTUS. 

but  as  the  foetus  may  be  either  more  or  less  straight,  there  will  arise 
numerous  discrepancies  in  the  results.  The  habitually  flexed  state 
of  the  lower  extremities  renders  it  too  difficult  to  extend  them  so  as 
to  comprise  their  length  in  a  rigorous  admeasurement  of  the  embryo. 

Authors  not  having  informed  us  which  of  these  methods  they 
adopted,  it  is  useless  to  look  further  for  the  reasons  of  the  discre- 
pancy observable  in  their  accounts  of  this  subject.  It  is  true  that 
the  most  minute  precautions  will  not  permit  us  to  specify,  within  one 
line,  the  length  of  a  foetus  more  than  a  month  old  ;  but  happily,  such 
a  degree  of  precision  can  be  a  matter  of  small  moment  in  the  eyes 
of  the  observer.  In  the  present  instance,  the  measurements  that  I 
shall  point  out  must  in  general  be  understood  as  applying  to  the 
foetus  in  its  naturally  curved  position,  that  is,  the  space  extending 
from  the  occiput  to  the  coccyx  ;  and  I  believe  this  diameter  never 
exceeds  eighteen  or  twenty  lines  before  the  end  of  the  second  month. 

608.  The  skin  of  the  human  embryo  has  no  real  existence  until 
at  a  pretty  advanced  period  of  its  growth,  while  the  sort  of  circle 
which  it  at  first  constitutes,  is  nothing  more  than  a  homogeneous 
gelatinous  substance  of  slight  consistency ;  the  epidermis  cannot  be 
distinguished  from  the  skin  until  after  the  second  month. 

509.  At  three  months  the  teguments  are  distinct,  but  still  gelati- 
nous and  of  a  rose  colour.  The  eye-lids  and  mouth  remain  shut ; 
the  nose  is  very  projecting,  the  head  very  large ;  the  costal  arches 
and  bones  of  the  fore-arm  are  visible  through  the  transparent  sub- 
Stances  in  which  they  are  inclosed.  The  fingers  and  toes  are  per- 
fectly distinct,  and  covered  on  the  dorsal  surface  of  their  extremities 
■with  a  reddish  plate  which  possesses  the  shape  of  the  nail ;  from  the 
vertex  to  the  coccyx  the  foetus  is  three  inches  in  length. 

510.  At  four  months  the  skin  is  much  firmer,  and  at  certain 
points  is  furnished  with  adipose  granulations.  The  head  begins  to 
be  covered  with  down  ;  the  scrotum,  or  the  greater  and  lesser  labia 
are  formed  ;  the  anus  is  open ;  and  if  in  the  measurement  we  comprise 
the  lower  extremities,  which,  notwithstanding  the  common  opinion 
to  the  contrary,  are  as  long  as  the  thoracic  members,  the  foetus 
will  be  from  five  to  six  inches  in  length. 

511.  M  five  months  a.  \\i\\e  down  and  some  particles  of  seba- 
ceous matter  are  observable  upon  various  portions  of  the  skin ;  the 
hairs  begin  to  grow,  but  are  still  white,  or  without  any  determinate 
colour.  The  teguments  are  less  transparent,  although  still  of  a  rose 
colour,  and  l)iit  slightly  extensible  ;  the  nails  arc  evident;  the  umbili- 
cal cord  far  removed  from  the  penis  or  clitoris.  No  pupil  can  be 
♦lislinguished,  and  the  fujtus  is  from  six  to  seven  inches  long. 


THE  FCETUS.  199 

612.  At  six  months,  the  period  of  viabilite,  the  down  and  the 
sebaceous  deposit  are  visible,  at  least  in  the  axillae  and  groins.  The 
hairs  of  the  head  may  be  easily  distinguished  from  those  that  grow 
upon  other  parts  of  the  body ;  the  eyelids  are  no  longer  transparent : 
it  has  been  said  that  there  is  at  this  period  no  pupil ;  but  it  has  ap- 
peared to  me,  on  the  contrary,  to  be  extremely  large  ;  the  xiphoid 
cartilage  occupies  the  middle  of  the  great  axis  of  the  fcEtus,  whose 
whole  length  is  from  eight  to  nine  inches. 

613.  At  seven  months  the  hair  is  longer,  and  not  so  pale,  the 
down  and  cutaneous  induitus  more  generally  diffused  ;  the  skin  is 
less  coloured  ;  the  nails  are  large  ;  the  membrana  pupillaris  bursts, 
according  to  the  authors ;  but  it  is  by  no  means  certain  that  this 
membrane  really  exists  in  the  manner  usually  understood  :  I  have 
reason  to  think  that  the  iris  originates  at  first  as  a  simple  ring,  which 
grows  concentrically,  so  as  at  last  to  leave  the  opening  commonly 
called  pupil  or  apple  of  the  eye.  The  riavel  is  still  below  the  middle 
of  the  foetus  ;  the  external  genital  organs  are  all  apparent,  except 
the  testicles  in  the  male,  and  the  foetus  is  about  ten  inches  long. 

514.  At  eight  months  the  foetus  is  only  distinguished  by  its  greater 
maturity  ;  its  length  is  about  eleven  inches.  Its  hair  is  more  or  less 
coloured  ;  its  skin,  covered  with  sebaceous  matter  and  down,  is  thick, 
and  not  so  smooth  as  before ;  the  lower^w,  which  at  first  was  very 
short,  is  now  almost  as  long  as  the  upper  one,  and  the  nails  exhibit 
a  certain  degree  of  consistency. 

615.  At  term.  The  development  and  weight  of  a  well  formed 
foetus,  at  term,  are  far  from  being  alike  in  all  cases.  The  knowledge 
of  them,  however,  even  if  approximative,  is  so  important  ia^he 
practice  of  midwifery,  that  their  extremes  and  average  ought  to  be 
sought  for  with  great  care.  At  this  period,  the  length  of  the  occipito- 
coccygeal  diameter  is  twelve  inches,  but  the  average  length  of  a 
foetus  straightened  out,  and  taken  from  the  heel  to  the  vertex,  is 
eighteen  inches,  according  to  the  very  multiplied  experiments  of 
professor  Chaussier ;  seventeen,  sixteen,  nineteen,  twenty,  and  even 
twenty-two  inches,  are  also  pretty  common  measurements,  but  it  is 
rare  to  meet  with  only  twelve  inches,  or  to  find  twenty-three.  The 
instances  of  children  twenty-six,  twenty- eight,  thirty,  and  even  thirty- 
six  inches  in  length,  or  of  only  ten,  eight,  or  even  six  inches,  which 
we  find  in  old  scientific  collections,  instances  which  the  common 
people  always  receive  with  cordiality,  may  be  boldly  classed  among 
other  popular  stories. 

516.  The  weight  of  a  foetus  is  generally  six  pounds,  frequently 
six  and  a  half  or  seven,  sometimes  eight,  and  rarely  nine  or  ten 


200 


THE  FCETUS. 


pounds.  Among  four  thousand  children,  born  at  the  Maternite  at 
Paris  in  a  given  time,  Madame  Lachapelle  never  met  with  one 
weighing  as  much  as  twelve  pounds.  Baudelocque,  who  had  a  case 
where  the  child  weighed  twelve  pounds  and  three  quarters,  main- 
tains that  it  is  incredible  that  a  larger  one  was  ever  seen  ;  the  weight 
of  the  child  also,  according  to  Chaussier,  is  frequently  only  five, 
four,  and  sometimes  three,  or  two  and  a  half  pounds;  but  in  the 
latter  instances,  it  seems  to  me  evident  that  pregnancy  had  not 
reached  its  full  term. 

517.  Out  of  the  profession,  we  daily  hear  of  children  weighing 
fifteen,  eighteen,  twenty,  twenty-five,  and  even  thirty  pounds  at  birth  : 
those  stories  too,  which  may  be  found  in  many  authors  of  the  six- 
teenth, seventeenth,  and  even  of  the  eighteenth  century,  are  owing 
to  the  fact,  that  persons  who  will  not  take  the  trouble  to  weigh  such 
children,  very  easily  attribute  a  weight  of  twelve  or  fifteen  pounds  to 
children  that  actually  weigh  only  seven  or  eight.  In  fact,  a  new 
born  child  of  eight  or  nine  pounds  is  enormous  ;  the  persons  sur- 
rounding the  lying-in  woman,  when  they  see  such  an  one,  rarely  fail 
to  cry  out  that  it  is  a  child  of  twelve  or  fifteen  pounds  ;  and  it  is 
very  likely  that,  in  order  to  render  the  fact  still  more  curious,  four  or 
five  pounds  will  be  added  to  its  weight  after  the  fifth  or  sixth  repe- 
tition of  the  story.  In  order  to  reduce  such  fables,  which  are  founded 
upon  gross  errors  of  observation,  to  their  real  value,  it  is  only  neces- 
sary to  reflect  that  thirty  pounds  is  the  weight  of  children  of  from 
two  to  three  years  of  age. 

518.  If  the  absolute  length  of  the  foetus  is  subject  to  such  great 
varieties,  it  is  easy  to  conceive  that  the  relative  length  of  different 
parts  of  it  cannot  be  more  precise  and  determinate.  Nevertheless, 
we  are  sometimes  obliged  in  medical  jurisprudence  to  have  recourse 
to  it  in  order  to  determine  the  age  of  a  given  foetus.  According  to 
Chaussier,  taking  eighteen  inches  as  a  mean  term,  there  are  ten 
inches  and  four  lines  from  the  vertex  to  the  navel,  and  seven  inches 
eight  lines  from  the  navel  to  the  sole  of  the  foot ;  eleven  inches  nine 
lines  from  the  pubis  to  the  vertex  ;  six  inches  three  lines  from  the 
pubis  to  the  sole  of  the  foot ;  two  inches  three  lines  from  the  clavicle 
to  the  lower  end  of  the  sternum,  and  six  inches  from  the  extremity 
of  the  sternum  to  the  pubis.  From  the  top  of  one  acromion  to  the 
other  we  find  four  inches  and  a  half,  which  may  be  easily  reduced 
to  three  inches  and  a  half  by  squeezing  the  shoulders  together. 
The  greatest  antcro-posterior  thickness  of  the  thorax  is  four  inches 
and  a  half,  while  there  arc  only  three  inches  from  one  crista  of  the 
ilium  to  the  other. 


THE  FGETUS.  201 

§.  IV.  Of  the  fetal  head,  at  term. 

519.  The  head,  being  of  all  parts  of  the  fcEtus  the  largest  and 
most  incompressible,  ought  to  be  studied  with  the  most  particular 
care.  The  bones  of  which  it  is  composed,  its  articulations,  its 
diameters,  its  motions,  and  the  degree  of  reduction  it  is  susceptible 
of,  ought  to  be  perfectly  known  to  the  practitioner  who  desires  not 
to  be  more  dangerous  than  useful  in  applying  the  assistance  of  the 
art  to  cases  of  dystocia.  It  is  composed,  as  in  the  adult,  of  the 
cranium,  which  is  its  most  interesting  part,  and  of  the  face,  which  is 
as  yet  but  little  developed,  and  whose  pieces  consist  of  the  ossa  nasi, 
the  ossa  malarum,  the  ossa  maxillaria  superiora,  the  ossa  unguis, 
the  ossa  palati,  the  ossa  spongiosa  inferiora,  the  vomer,  and  the  os 
maxillare  inferior. 

620.  Form.  The  head  of  the  foetus,  chiefly  remarkable  from  the 
flexibility  of  its  vault,  exhibits  in  its  ensemble  the  form  of  an  oval,  the 
attitude  of  which  has  occasioned  a  sort  of  literary  quarrel  between 
MM.  Capuron  and  Van  Solingen  :  the  former  of  these  authors 
insists  that  the  large  extremity  of  the  head  is  turned  backwards, 
while  the  latter,  who  is  also  followed  by  M.  Duges,  places  it,  on 
the  contrary,  in  front.  If  the  external  occipital  protuberance  occu- 
pies the  centre  of  the  strait  in  labour,  it  is  difiicult  not  to  agree  with 
the  Dutch  accoucheur,  that  the  large  extremity  of  the  oval  is  repre- 
sented by  the  face ;  but  when  we  take  hold  of  the  head  by  the  chin, 
its  large  extremity  is  undoubtedly  to  be  found  posteriorly.  In  this 
case,  as  in  many  others,  the  dispute  is  rather  about  words  than  things  ; 
both  sides  are  right,  and  both  are  wrong  in  some  respects.  How- 
ever, by  reflecting  that  all  the  diameters  of  the  posterior  part  of  the 
head  are  three  inches  and  a  half  in  length,  while  the  longest  of 
those  of  the  face  is  only  three  inches  at  most,  it  will  be  evident  that 
we  ought  to  adopt  the  opinion  of  our  countryman,  and  say  that  the 
large  extremity  of  the  fcctal  head  is  formed  by  the  occiput. 

521.  Diameters.  The  axes  or  diameters  of  the  head  are  imagi- 
nary lines,  which  pass  through  it  in  determinate  directions.  They 
may  be  multiplied  ad  infinitum ;  but  those  only  that  are  liable  to  be 
placed  in  certain  relations  to  the  axes  or  diameters  of  the  pelvis,  de- 
serve our  attention.  1  think  that  it  is  sufficient  to  describe  seven  : 
1.  The  occipito-Ttiental,  five  inches  in  length,  extending  from  the 
most  projecting  part  of  the  occiput  to  the  point  of  the  chin,  also 
called  the  great  or  oblique  diameter,  and  which  M.  Flamant  de- 
nominates the  sur-occipito-mcntal ;  2.  The  occipito-frontal.,  about 
four  inches  long,  which  extends  from  the  occij^ital  protuberance 
to  the  forehead,  and  which  is  also  called  the  straight  or  antero- 
posterior diameter ;  3.  The  hi-parietal.  or  transverse  diametoi, 
2  A 


202  THE  FCETUS. 

reaching  from  one  parietal  protuberance  to  the  other,  and  which 
is  three  inches  and  a  half;  4.  The  bi-temporal^  or  smallest  diameter, 
measured  from  the  root  of  one  zygomatic  apophysis  to  the  opposite 
one,  and  whose  length  is  two  inches  and  a  half;  5.  The  vertical  or 
trachelo-bregmatic^  which  passes  through  the  head  perpendicularly, 
descending  from  the  vertex  to  the  anterior  part  of  the  occipital  fo- 
ramen, and  is  about  three  inches  and  a  half;  6,  The fronto-menial, 
or  facial,  whose  name  sufficiently  indicates  its  situation,  and  whose 
extent  is  three  inches  ;  7.  Finally,  the  occipito-bregmatic^  the  most 
important  of  all,  whose  posterior  extremity  is  situated  between  the 
occipital  protuberance  and  foramen  magnum,  and  proceeds  to  ter- 
minate at  the  anterior  fontanelle ;  its  length  is  nearly  three  inches* 
and  three  quarters. 

522.  Circuviferences.  These  various  diameters  are  accompanied 
with  an  equal  number  of  circumferences,  which  should  receive  the 
same  names,  and  whose  lengths  are  equally  various :  1 .  The  occipito- 
mental or  great  circumference,  which  divides  the  head  into  two  late- 
ral halves  exactly  similar  to  each  other,  passes  at  the  same  time  over 
both  extremities  of  the  occipito-mental  diameter,  and  which,  when 
multiplied  by  three,  equals  the  length  of  the  circumference,  and  also 
over  those  of  the  fronto-mental,  occipito-frontal,  vertical,  and  occipilo- 
bregmatic ;  2.  The  facial  circumference,  which  passes  over  the 
forehead,  the  chin,  and  the  cheeks ;  3.  The  circumference  of  the 
vertical  diameter^  which  passes  a  little  in  front  of  the  parietal  pro- 
tuberances, and  thus  divides  the  head  transversely  ;  4.  That  of  the 
occipito-frontal  diameter,  which  at  the  same  time  embraces  the  ex- 
tremes of  the  transverse  diameter,  and  separates,  horizontally,  the 
vault  from  the  base  of  the  cranium  ;  5.  That  of  the  occipito-hreg- 
matic  axis,  which  is  also  the  special  circumference  of  the  bi-parietal 
diameter,  and  the  most  important  of  all,  for  in  all  natural  labours  it 
is  found  in  relation  with  the  circle  of  the  pelvic  straits  ;  6.  Finally, 
the  circumference  of  the  bi-tcmporal  or  smallest  diameter  should 
pass  also  over  both  ends  of  the  vertical  or  occipito-bregmatic  ;  its 
existence  ought  not  to  be  admitted  except  in  the  greatest  possible 
degree  of  reduction  of  the  head  ;  a  knowledge  of  it  then  becomes  of 
the  highest  practical  interest,  for  by  comparing  its  line  of  tension, 
that  is  to  say,  its  bi-temporal  axis  with  the  vitiated  diameters  of  the 
pelvis  through  which  the  child  has  to  pass,  wo  can  ascertain  whe- 
ther delivery  be  practicable  or  not. 

523.  Varieties.  It  is  not  necessary  for  me  to  observe  that  these 
measurements  should  be  taken  merely  as  mean  terms,  and  tliat  tiierc 
is'no  more  unif<jrmiiy  in  the  size  of  the  fcDtal  head  than  in  the  other 
parts  of  lijc  body ;  but  I  ought  not  to  fail  to  remark, '  that  they  are 


THE  FCETUS.  203 

susceptible  of  various  degrees  of  reduction  or  elongation,  whether 
by  means  merely  of  the  uterine  contractions,  or  by  the  mechanical 
action  of  the  instruments  that  are  sometimes  employed  in  midwifery. 
Thus  the  occipito-frontal  diameter,  when  compressed  at  its  extre- 
mities, may  be  shortened  several  lines,  by  the  over-riding  of  the 
corresponding  edges  of  the  frontal,  parietal,  and  occipital  bones. 
The  same  is  true  of  the  transverse  and  occipito-bregraatic  axes, 
whenever  the  pressure  bears  chiefly  on  the  two  opposite  points  of 
their  circumference ;  but  in  order  to  form  a  clear  idea  of  the  changes 
that  the  head  may  undergo  in  this  regard,  it  is  indispensably  neces- 
sary to  obtain  correct  notions  as  to  the  arrangement  of  the  bones  of 
the  head  at  birth. 

524  Bones  of  the  skull.  In  the  foetus  at  term,  the  eight  bones 
of  the  skull,  the  frontal,  occipital,  the  two  parietal,  the  two  tem- 
poral, the  sphenoid,  and  ethmoid  bones  are  far  from  possessing  the 
same  firmness  as  those  of  the  adult ;  those  of  the  vault  are  still  quite 
flexible,  and  separated  from  each  other  by  membranous  spaces  of 
greater  or  less  size  ;  the  frontal  is  formed  of  two  symmetrical  pieces  ; 
the  thin  or  flattened  portion  of  the  occipital  and  the  squamous  portion 
of  the  temporal  are  pretty  frequently  separate  from  the  petrous  and 
condyloid  portions  respectively  ;  the  basilar  apophysis,  the  body  of 
the  sphenoid,  the  petrous  portion  of  the  temporal,  and  the  several 
pieces  which  constitute  the  base  of  the  cranium,  are  on  the  contrary 
almost  completely  ossified,  or  at  least  form  with  the  cartilages  which 
unite  them  an  incompressible  mass. 

525.  From  the  above  arrangement  it  follows,  1 .  That  the  diame- 
ters of  the  vault  of  the  cranium  alone  are  reducible  in  labour ; 
2.  That  whenever  the  diameters  of  the  pelvis  are  smaller  than  those 
of  the  base  of  the  foetal  skull,  delivery  is  physically  impossible  without 
the  aid  of  art ;  3.  That  in  this  way  the  medulla  oblongata,  the 
pons  varolii,  the  tubercula  quadrigemina,  and  the  peduncles  of  the 
cerebrum  and  cerebellum,  are  completely  protected,  while  the  cere- 
bral and  cerebellar  lobes,  which  are  almost  unconnected  with  the 
maintenance  of  the  vegetative  life  of  the  foetus,  are  alone  liable  to 
be  slightly  compressed. 

The  numberless  varieties  of  which  the  dimensions  of  the  head  are 
susceptible  has  long  since  convinced  accoucheurs  of  the  necessity 
of  discovering  some  means  by  which  to  ascertain  what  they  are  in 
the  foetus  while  still  contained  within  the  maternal  organs ;  but  it  must 
be  confessed,  notwithstanding  M.  Flamant's  opinion,  that  all  attempts 
of  the  sort  have  been  hitherto  fruitless.  But  while  I  release  the 
reader  from  a  tedious  description  or  even  enumeration  of  all  the 
different  methods  that  have  been  proposed  at  various  periods,  it 


204  THE  F(ETUS. 

seems  indispensably  necessary  for  mo  to. say  a  few  words  on  the 
researches  of  one  of  my  former  fellow  students  upon  this  subject. 

626.  Mensuration.  By  measuring  a  certain  number  of  dried 
heads,  M.  Fouilhoux  ascertained,  1.  That  a  line  drawn  from  the 
fronto-nasal  suture  to  the  edge  of  the  upper  alveoles,  represents, 
very  nearly,  one  half  of  another  line,  drawn  from  the  superior  angle 
to  the  great  foramen  of  the  occipital  bone ;  2.  That  the  space  be- 
tween the  fronto-nasal  and  fronto-parietal  sutures  is  equal  to  that 
which  extends  from  the  posterior  edge  of  the  coronal,  and  the  point 
of  the  occipital ;  3.  That  by  adding  five  or  six  lines  to  the  occipital 
arch  we  obtain  the  length  of  the  sagittal  suture ;  4.  That  the  bi- 
parietal  diameter  is  six  lines  longer  than  the  sagittal  suture; 
5.  That  the  facial  line  multipUed  by  three  also  gives  the  length  of 
the  transverse  diameter;  6.  That  the  occipito-frontal  diameter 
exceeds  the  bi-parietal  by  nine  lines.  So  that  if  we  can  succeed 
during  labour  in  measuring,  with  any  degree  of  precision,  either  the 
fronto-maxillary  line,  or  the  naso-parietal  arch,  or  the  occipital  arch, 
or  lastly,  the  sagittal  suture,  it  is  afterwards  easy  to  determine  the 
antero-posterior  and  transverse  diameters  of  the  cranium. 

527.  The  assertions  of  M.  Fouilhoux,  subjected  to  pretty  nume- 
rous experimental  tests,  have  appeared  to  me  to  be,  in  general, 
correct;  but  I  have  also  found  that  the  proportional  differences 
which  he  endeavours  to  establish  are  too  vafiable  to  admit  of  their 
being  very  usefully  employed  in  practice.  Even  were  they  to  prove 
constantly  and  rigorously  correct,  how  shall  we  ever  be  able  to  dis- 
tinguish through  the  soft  parts,  and  within  the  maternal  organs,  the 
precise  length  of  the  occipital  arch,  or  the  frontal  arch,  or  even  the 
facial  line?     The  thing  appears  to  me  to  be  impossible. 

528.  The  sutures  of  the  foetal  cranium  are  more  numerous,  more 
movable,  and  wider  than  those  of  the  adult.  As  they,  together 
with  the  fontanels,  serve  to  mark  the  positions  of  the  licad,  it  is 
very  important  for  the  accoucheur  to  have  them  always  present  to 
his  memory. 

TIic  sagittal,  straight,  or  antero-posterior  suture  extends  from 
the  root  of  the  nose  to  the  superior  angle  of  the  occipital  bone,  and 
may  be  divided  into  two  portions,  the  naso-parietal,  which  unites 
the  two  pieces  of  the  frontal  bone,  and  the  parietal  portion,  which 
is  formed  by  the  conjunction  of  the  two  parietal  bones  at  their  supe- 
rior edges.  Tlie  fronto-parietal.,  coronal,  transverse  or  anterior 
suture  crosses  the  vne  above  mentioned  at  right  angles,  at  the  place 
where  its  two  halves  unite.  The  occipifo-pnrictal,  lanibdoidal,  pos- 
terior or  occipital  suture  seems  to  be  only  a  bifurcation  of  the 
sagittal:  as  the  s<iuamou8,  or  temporo-parietal  sutures  are  con. 


THE  FOETUS.  205 

cealcd  tinder  a  thick  layer  of  soft  parts,  they  hardly  deserve  to  be 
mentioned  in  a  work  on  midwifery. 

529.  The  lamhdoidal  suture,  so  called  from  its  resemblance  to 
the  Greek  a  is  perhaps  the  most  frequent  cause  of  error,  as  it  may 
be  mistook  for  the  fronto-parietal.  It  differs  from  it,  however,  be- 
cause its  two  branches,  which  are  oblique  to  each  other  and  to  the 
sagittal  suture,  really  form  two  distinct  and  independent  sutures, 
while  the  two  moieties  of  the  anterior  suture  are  only  continuations 
of  each  other,  and  constitute  but  one  and  the  same  hne. 

630.  There  are  usually  found  at  the  points  where  these  sutures 
cross  or  terminate,  certain  membranous  spaces  called  fontanels  or 
fountains  of  the  brain. 

The  anterior  or  frontal  fontanel,  which  is  sometimes  called  the 
bregmatic  fontanel,  because  it  in  fact  answers  to  the  bregma^  forms 
the  common  point  of  union  of  four  bony  angles,  viz.  the  superior  angles 
of  the  two  portions  of  the  frontal  bones,  and  the  two  antero-su- 
perior  angles  of  the  parietal  bones  ;  it  is  larger  or  smaller  accord- 
ingly as  these  angles  are  sharper  or  rounder  ;  it  is  of  a  lozenge 
shape,  and  generally  extends  much  farther  between  the  two  portions 
of  the  coronal  than  of  the  parietal  bones. 

The  posterior^  or  occipital  fontanel,  which  forms  a  part  of  the 
summit  of  the  head,  is  situated  at  the  spot  where  the  sagittal  loses 
itself  in  the  lambdoidal  suture  ;  it  is  always  very  narrow,  and  in 
some  subjects  scarcely  distinguishable ;  its  triangular  shape  pre- 
vents it  from  being  mistaken  for  the  one  before  mentioned  ;  but  as 
a  middle  suture  sometimes  divides  the  occipital  bone  into  two 
pieces,  and  as  the  superior  angle  of  this  bone  is  sometimes  wanting, 
it  must  be  remembered  that  only  three  branches  issue  from  this  fon- 
tanel, or  if  there  should  be  four,  the  two  lateral  branches  proceed 
obliquely  towards  the  mastoid  processes,  and  do  not  cross  the  other 
at  right  angles,  as  is  the  case  at  the  anterior  fontanel.  This  is  the 
most  important  fontanel,  since  it  indicates  the  presence  of  the  sum- 
mit of  the  head. 

The  inferior  or  lateral  fontanels,  four  in  number,  two  on  each 
side,  are  found  at  the  points  of  termination  of  the  anterior  and  pos- 
terior sutures,  and  are  of  no  use  in  the  practice  of  midwifery. 

531.  The  head  is  further  divided  into  five  regions  or  ovals:  one 
superior,  in  which  is  to  be  observed,  the  summit  beiiind,  the  bregma 
and  sinciput  in  front,  the  vertex  in  the  middle,  and  which  is  bound- 
ed below  by  the  occipito- frontal  circumference  ;  another,  inferior, 
which  is  represented  by  the  base  of  the  cranium  and  posterior  part 
of  the  face  ;  a  third,  anterior  or  facial,  which  is  enclosed  in  the 
fronto-mental  circumference  ;    the   two   last,  lateral  or  temporal, 


lr» 


206  THE  FCETUS. 


which  comprise  whatever  is  left  out  by  the  other,  and  whose  dimen- 
sions have  reference,  in  labour,  to  those  of  the  occipito-mental 
diameter,  which  renders  presentations  of  them  highly  disadvanta- 
geous. 

532.  The  articulation  of  the  head  with  the  vertebral  column 
merits  the  most  serious  attention  ;  for  want  of  a  careful  study  of  it 
a  vast  number  of  accoucheurs  and  midwives  bring  children  still  born 
into  the  world,  who,  a  few  minutes  before,  were  strong  and  full  of 
vigour. 

The  union  of  the  atlas  with  the  occipital  bone  is  a  very  close  ar- 
ticulation, which  scarcely  admits  of  any  motion  except  flexion  and 
extension  ;  that  of  the  atlas  with  the  axis  is  a  rotatory  ginglymus, 
so  arranged,  that  if  the  pivot  motion  of  the  head  is  carried  beyond 
a  quarter  of  a  circle,  the  articular  surfaces  immediately  separate, 
and  the  spinal  marrow  is  at  the  same  moment  compressed,  torn,  or 
even  entirely  broken  off;  so  that,  if  the  chin  of  the  foetus  turns  so 
far  as  to  pass  behind  the  point  of  the  shoulder,  death  ensues  im- 
mediately. On  the  other  hand,  it  is  in  the  occipito-vertebral  articu- 
lation that  we  find  the  cause  of  the  so  frequent  presentations  of  the 
vertex  rather  than  the  face.  In  fact,  when  seen  in  an  antero-pos- 
terior  direction,  the  head  resting  on  the  top  of  the  spine  represents 
a  lever  of  the  third  kind  ;  during  the  efforts  of  parturition,  the  power 
being  evidently  represented  by  the  vertebral  column,  the  points  of  • 
rest  and  of  resistance  must  necessarily  be  met  with  at  the  extremi- 
ties of  the  occipito-mental  diameter.  Now,  if  the  occiput  almost 
always  descends  first,  while  the  chin  descends  but  very  rarely,  it 
depends  upon  the  more  advantageous  action  of  the  power  upon  the 
occipital  than  upon  the  opposite  extremity  of  this  lever,  the  condyles 
being  nearer  the  former  than  the  latter  of  these  points. 

§.  V.  Of  the  attitude,  and  position  of  the  foetus  during  preg- 
nancy. 

533.  During  the  whole  course  of  pregnancy  the  foetus  is  bent 
forwards,  so  as  to  form  a  kind  of  circle,  more  or  less  complete ;  at 
full  term  it  is  found  with  the  head  bent  forwards  on  the  breast,  the 
feet  turned  up  to  the  front  part  of  the  legs,  the  legs  against  the  hind 
part  of  the  thighs,  the  thighs  on  the  anterior  surface  of  the  abdo- 
men, the  heels  crossed  and  very  near  the  ischia,  the  arms  applied 
to  tlic  sides  of  the  thorax,  the  fore-arms  bent,  and  crossed  in  front 
of  ^thc  sternum,  as  if  to  support  the  chin  betwixt  the  two  hands. 
It  therefore  forms  an  oval  mass  whose  large  end  is  represented  by 
the  pelvic  extremity  of  the  trunk,  and  its  apex  by  the  cephalic  ex- 
tremity.    In  this  state  its  great  or  occipito-cocci/geal  diameter  is 


THE  FCETUS.  207 

only  ten  or  twelve  inches  in  length,  and  may  even  be  shortened  one 
or  two  inches  by  pressure  exerted  upon  its  two  extremities. 

634.  It  may  be  affirmed,  in  general,  that  the  laws  of  gravity  de- 
termine the  position  of  the  foetus,  until  the  last  stage  of  gestation ; 
suspended  in  the  centre  of  the  ovum  by  means  of  the  umbilical 
cord,  loose  and  very  movable  in  the  amniotic  liquor,  it  necessarily 
falls  to  the  lowest  point  of  the  cavity  in  which  it  is  contained  :  the 
cord  being  inserted  much  nearer  to  the  coccyx  than  to  the  occiput, 
renders  it  necessary  for  the  cephalic  extremity  of  the  foetus  to  fall 
to  the  lowest  part  of  the  womb  :  therefore,  since,  even  when  the 
woman  is  lying  down,  the  neck  is  lower  than  the  fundus  of  the 
womb,  it  is  clear  that  the  head  must  naturally  be  turned  towards 
the  superior  strait  in  a  great  majority  of  cases,  as  is  proved  by  daily 
experience. 

535.  However,  the  ancients  entertained  a  different  opinion  ;  ac- 
cording to  them,  the  foetus  has  its  head  upwards,  the  pelvic  extremity 
turned  towards  the  margin  of  the  pelvis,  and  the  hinder'  part  of 
the  breech  resting  against  the  sacro-vertebral  angle,  until  about  the 
seventh  month  ;  then,  by  means  of  certain  quick  and  somewhat 
convulsive  motions,  it  turns  over,  performing  a  somerset :  so  that 
the  forehead  comes  to  take  the  place  of  the  breech,  and  vice  versa. 
This  hypothesis,  generally  adopted  until  the  time  of  Baudelocque, 
and  since  that  period  still  defended  by  several  authors,  principally 
in  Germany,  is  now  abandoned  to  the  vulgar,  who  also  are  begin- 
ning to  give  it  up. 

536.  If  a  pregnant  woman  dies  before  the  seventh  month  of  ges- 
tation, the  head  of  the  foetus  is  found  turned  towards  the  neck  of  the 
uterus,  just  as  it  is  at  the  full  term.  I  have  opened  the  bodies  of 
three  women  who  died  between  the  third  and  sixth  months  of  their 
pregnancy,  and  in  these  three  cases  the  occiput  was  below.  Who 
has  not  seen  the  foetus  come  head  foremost  in  abortion  as  at  the 
full  period?  From  October  1823  to  the  month  of  April  182G, 
eight  miscarriages  of  from  four  to  seven  months  took  place  under 
my  care  at  the  Hospital  de  Perfectionnement ;  I  have  observed  nearly 
the  same  number  in  ray  private  practice,  and  at  my  public  lying-in 
ward  :  but  in  all  these  cases  I  found  the  breech  presenting  in  only 
two  instances.  Further,  it  is  not  uncommon  to  find  the  neck  suffi- 
ciently softened  before  the  seventh  month  to  permit  the  finger  to 
pass  in  so  as  to  touch  the  naked  ovum  in  the  womb,  and  we  almost 
always  find  that  the  head  is  downwards.  Another  reason  advanced 
by  the  moderns  as  decisive,  but  which  if  taken  singly  would  liot  ap- 
pear to  me  to  be  very  conclusive,  is  derived  from  the  length  of  the 
foetus,  compared  with  the  dimensions  of  the  uterine  cavity.    It  has 


308 


THE  FOETUS. 


been  said,  since  the  foetus  after  the  sixth  month  is  from  ten  to 
twelve  inches  long,  it  is  physically  impossible  for  it  to  turn  after  that 
period  in  the  cavity  of  the  womb,  whose  transverse  and  antero- 
posterior diameters  do  not  exceed  six  or  eight  inches :  no  doubt ; 
but  they  forget  that  the  foetus  is  doubled  up  in  the  amnios,  and  in- 
stead of  twelve,  its  long  diameter  is  only  six  or  eight  inches  long ; 
they  also  forget,  that  even  at  full  term  the  child  sometimes  changes 
its  position  during  labour,  and  that  even  at  the  period  of  its  greatest 
development,  the  diameter  passing  from  its  occiput  to  the  coccyx 
does  not  always  exceed  the  length  of  the  horizontal  diameter  of  the 
womb. 

It  is  not  therefore  correct  to  maintain  that  the  proportional 
dimensions  of  the  uterus  and  foetus  raise  an  insurmountable  barrier 
to  the  somerset  motion  ;  if  this  transposition  has  no  existence,  it  is 
because  the  relative  weight  of  the  head  renders  it  unnecessary. 

§.  VI.  Of  superfoetation. 

637.  The  name  of  superfoetation  is  given  to  the  vivification  of  a 
germ,  in  a  woman  who  already  contains  a  fecundated  ovule  in  some 
part  of  her  generative  system. 

The  existence  and  the  possibility  of  this  fact,  admitted  and  denied 
by  turns  by  the  physicians  of  all  ages,  constitutes  a  question  upon 
which  modern  naturalists  have  not  as  yet  decided.  The  ancients 
have  handled  it  so  slightly,  that  it  is  really  useless  to  oppose  them. 
According  to  Aristotle,  "  cases  of  superfoetation  have  been  seen  in 
women,  and  twelve  foetuses  have  been  seen  to  come  away  in  a  single 
miscarriage,  in  this  manner.  When  the  two  foetuses  have  been  pro- 
duced soon  after  each  other,  they  are  born  as  if  they  had  been  twins, 
as  the  poets  tell  us  of  Iphiclcs  and  Hercules."  The  philosopher 
also  cites,  as  an  instance  of  superfoetation,  a  woman  who  brought 
into  the  world  two  children,  one  resembling  her  husband  and  the 
other  her  lover ! 

638.  Almost  all  the  cases  wo  have  of  superfoetation  seem  to  me 
to  be  referable,  1 .  To  twin  pregnancies,  in  which  one  of  the  chil- 
dren, having  died  long  before  the  full  term,  has  been  preserved 
within  the  membranes,  not  to  be  expelled  until  the  other  vviiich  con- 
tinued to  live  ;  2.  To  pregnancies  of  twins  unequally  developed,  or 
born  at  diflbrcnt  periods ;  3.  To  Cases  of  extra- ulc line  pregnancy, 
which  did  not  interfere  with  natural  gestation  ;  4.  Lastly,  to  cases 
of  double  uterus. 

639.  Nothing  is  more  common  than  lo  sec,  in  compound  prog- 
nancy,  one  of  tlic  f(x:lUbC3  lose  its  Ufc,  and  when  born  exhibit  the 
appearances  of  a  fatus  of  from  two  to  six  months,  although  in  fact 


SUPERFCETATION.  209 

it  is  nine  months  old,  and  every  body  knows  that  most  monsters  are 
met  with  in  company  with  a  well  formed  foetus. 

A  lady  of  la  Varenne,  near  Tours,  was  brought  to  bed  of  a  stout 
boy  in  1819  ;  with  the  afterbirth,  Mr  Mignot,  her  surgeon,  received 
•  another  foetus  enclosed  within  the  same  ovum,  but  without  a  head, 
neck  or  arms. 

A  lady  of  the  fauxbourg  Saint-Germain  was  delivered  in  1824  of 
a  vigorous  and  very  stout  child;  Madame  Forbet,  the  midwife,  brought 
me  the  afterbirth,  and  at  some  distance  from  the  umbilical  cord  I 
found,  supported  by  a  pedicle  two  inches  in  length,  a  fleshy  mass, 
in  which  were  the  evident  remains  of  a  foetus.  In  March  1827, 
M.  Baroilhet  had  the  kindness  to  give  me  a  monstrous,  product, 
which  possessed  neither  head  nor  members,  and  which  was  expelled 
together  with  a  healthy  foetus,  &c. 

In  1824,  at  the  Hospital  de  Perfectionnement,  I  received  at  the 
same  time  witt  a  full  grown  foetus,  a. dead  one,  which  as  to  devel- 
opment had  not  passed  beyond  the  third  month.  M.  Deferment 
has  shown  me  a  similar  instance.  In  the  month  of  October  1826, 
Madame  Badinier,  a  midwife,  brought  me  two  foetuses,  one  of  which, 
quite  deformed,  appeared  to  be  of  about  two  months,  and  the  other  of 
five  or  six  ;  they  had  both  escaped  from  the  same  ovum,  and  before 
the  full  term.  Bauhin  speaks  of  a  woman  who  gave  birth  on  the 
same  day  to  a  foetus  at  term,  and  to  an  embryo  as  long  as  the  finger, 
both  enclosed  in  a  single  envelope.  Ruysch  saw  the  wife  of  a  surgeon 
of  Amsterdam  delivered,  with  an  interval  of  two  hours,  of  one  child, 
full  of  life,  and  of  an  embryo  which  could  not  have  been  of  more 
than  three  months  growth,  with  its  cord  full  of  hydatids.  Percy 
speaks  of  a  woman  who,  after  giving  birth  to  a  small  but  lively  boy, 
brought  forth,  surrounded  by  a  black  fungous  mass,  a  female  foetus 
of  the  fourth  month,  in  a  pretty  good  state  of  preservation.  Lau- 
rette,  says  Zacchias,  was  delivered,  eight  months  after  the  death  of 
her  husband,  of  a  badly  formed  male  child,  which  never  gave  any 
signs  of  life.  One  month  and  one  or  two  days  after  this  she  was 
delivered  of  a  second  child,  which  was  in  good  health,  and  which 
lived. 

And  the  authors  conclude  that  these  were  cases  of  superfoetation  ! 

540.  2d.  When  two  foetuses  are  contained  within  the  uterus,  one 
may  grow  more  rapidly  than  the  other ;  one  may  be  expelled  before 
its  full  time,  and  the  other  not  be  born  till  some  time  afterwards,  &.c. 

To  tliis  class  belongs,  if  indeed  there  be  not  a  good  many  belong- 
ing to  the  same  category,  tlie  case  of  a  lady  named  Dupuis,  at  Saint- 
Germain-en-Laye,  who  hid  a  miscarriage  at  four  months  and  a  half, 
and  four  months  after  that  brought  a  healthy  boy  into  the  world  ; 
2B 


2JQ  THE  FffiTUS. 


the  case  which  MM.  Desgrange  and  Fodere  look  upon  as  decisive, 
and  in  which  B.  Franquet  was  dehvered  of  a  healthy  foetus  five 
months  and  sixteen  days  after  she  had  miscarried  of  a  seven  months' 
pregnancy ;  the  case  of  Madame  Bigaud,  who  on  the  30th  of  April 
1748  brought  forth  a  living  male  child,  and  notwithstanding  that,, 
was  delivered  on  the  i7th  of  the  following  September  of  a  second 
fcEtus  quite  as  strong  and  lively ;  another  communicated  by  M. 
Rexain,  in  which  one  of  the  children  was  born  three  months  after 
the  other ;  those  of  M.  Delmas  of  Rouen,  of  M.  Pignot  of  Issoudun, 
of  M.  Wendt  of  Breslaw,  of  Dr  Fahrenhost,  &c. 

541.  The  two  cases  by  B.  Franquet  and  Madame  Bigaud,  the 
one  mentioned  in  the  Recueil  de  la  Societe  de  Medecine,  in  which 
it  is  stated  that  a  woman  at  Aries  was  delivered  of  a  full  grown 
child  in  1796,  and  of  another,  also  at  full  term,  five  months  after- 
wards, in  1797;  another  by  Dr  Stearns,  in  which  a  negro  woman 
was  delivered  of  a  black  child'in  about  the  eighth  month,  and  a  few 
hours  afterwards  of  a  white  fcetus  of  about  four  months,  which  ex- 
hibited signs  of  life,  are  beyond  dispute  the  most  difiicult  to  under- 
stand. But  as  it  is  not  impossible  that  they  might  at  Lyons  have 
supposed  a  foetus  to"  be  seven  months,  when  in  fact  it  was  not  more 
than  five  months  old,  while  the  one  last  born  might  have  exceeded 
the  ninth  month  of  gestation  ;  and  as  they  might  have  made  the  same 
mistake  at  Strasburgh  ;  and  as  the  signatures  of  notaries  do  not  con- 
stitute evidence  in  such  cases,  we  may  be  permitted  to  suspect  that 
some  error  has  crept  into  these  stories. 

542.  3d.  When  an  extra-uterine  conception  takes  place,  the  womb 
sometimes  swells  and  becomes  filled  with  concrescible  matter,  as  in 
an  ordinary  conception ;  in  such  a  case  superfatation  appears  to  be 
impossible  :  but  if  the  womb  remains  in  the  same  state  as  before 
fecundation,  it  is  clear  that  a  new  conception  may  take  place  during 
the  existence  of  the  first  gestation.-  In  support  of  these  assertions, 
I  may  refer  to  an  instance  of  extra-uterine  pregnancy  which  lasted 
for  three  years,  during  which  time  the  woman  conceived  and  brought 
forth  a  well  formed  child  ;  and  another  case  for  which  we  arc  in- 
debted to  M.  Clict,  in  which  it  is  said,  that  in  a  woman  who  died 
suddenly,  one  foitus  was  found  behind  the  womb  in  the  excavation 
of  the  pelvis,  and  another  in  the  cavity  of  the  womb  itself. 

643.  4th.  When  the  womb  is  divided  into  two  cavities  by  a  perpen- 
dicular septum,  and  these  cavities  open  separately  into  the  vagina, 
it  is  evident  that  two  germs  may  be  fecundated  at  intervals  more  or 
less  remote ;  in  a  word,  that  superfoetation  may  take  place.  This 
is  the  way  in  which  the  following  fact  ought  to  be  understood,  which 
has  been  cited  by  M.  Caasan,  and  collected  by  Madame  Boivin  :  u 


SUPERFCETATION.  211 

woman  forty  years  of  age,  was  delivered  of  a  little  girl  on  the  15th 
of  March  1810;  the  cavity  of  the  uterus^  which  was  already  con- 
tracted, was  examined  without  any  thing  being  found  in  it ;  and  yet, 
this  woman,  whose  abdomen  had  remained  pretty  large,  gave  birth 
to  another  child  on  the  12th  of  May  of  the  same  year. 

544.  We  ought  also  to  admit  the  existence,  or  at  least  the  possi- 
bility of  another  kind  of  superfcetation.  A  woman  at  Charleston 
gave  birth  on  the  same  day  to  twin  children,  one  of  which  was  black 
and  the  other  white,  and  accounted  for  it  by  stating  that  after  leav- 
ing the  arms  of  her  husband  in  the  morning,  one  of  his  negroes, 
armed  with  a  pistol,  came  and  compelled  her  to  have  connexion  with 
him.  A  negro  woman  at  Guadaloupe  brought  forth  two  full  sized 
boys,  one  a  black  and  the  other  a  mulatto,  and  confessed  she  had 
had  connexion  on  the  same  evening  with  a  negro  and  a  white  man. 
Another  negro  woman  had  three  children  at  a  birth;  one  black,  one 
white,  and  the  third  a  cahre.  A  white  servant  girl  in  Montgomery 
county  brought  into  the  world  at  the  same  lying-in  a  white  girl 
and  a  boy  that  was  perfectly  black.  A  negro  and  a  white  servant 
both  disappeared  upon  learning  that  the  g;irl  was  pregnant.  Accord- 
ing to  M.  Gardien,  M.  Valentin  has  related  a  case  similar  to  the 
one  above.  A  mare  foaled  a  colt  and  a'  young  mule  at  an  interval 
of  a  quarter  of  an  hour ;  she  had  been  covered  by  a  horse,  and  five 
days  after  that  by  an  ass. 

545.  Granting  all  possible  authenticity  to  these  observations,  and 
supposing  their  correctness  to  be  demonstrated,  the  ideas  of  physio- 
logists that  prevail  at  the  present  day  admit  of  their  easy  explana- 
tion. Two  ovules  may  become  impregnated,  one  after  the  other,  in 
a  woman  who  grants  her  favours  to  two  or  more  men  on  the  same 
day  or  in  the  space  of  two  or  three  days,  that  is  to  say,  up  to  the 
moment  when  the  excitement  of  the  first  fruitful  coition  occasions 
the  effusion  of  that  coagulable  lymph  in  the  cavity  of  the  womb 
which  afterwards  becomes  the  membrana  caduca. 

546.  Of  two  germs  vivified  by  the  same  copulation,  one  may  not 
descend  into  the  uterine  cavity  until  a  considerable  time  after  the 
other ;  the  maturity  of  the  two  ovules  may  not  have  arrived  at  the 
same  degree  of  perfection  at  the  instant  of  their  union  with  the 
principle  furnished  by  the  male  ;  one  of  the  germs  may  happen  to 
be  disengaged  with  difficulty  from  the  ovary,  remain  adhering  to  it 
without  growing  with  the  same  rapidity  as  its  congener,  and  not 
escape  from  the  vesicle,  nor  pass  into  the  tube  until  after  a  greater 
or  less  lapse  of  time. 

547.  I  am  astonished  that  modern  physiologists,  and  even  some 
medico-jurists,  among  whom  should  be  mentioned  M.  Orfila,  have 


212  THE  FffiTUS. 

admitted  the  existence  of  superfoetation  up  to  the  moment  when  the 
ovule  reaches  the  womb,  while  they  deny  the  possibility  of  its  occur- 
ring after  that  period.  It  ought  to  bo  equally  rejected  in  both  cases. 
The  concrescible  lymph  or  anhistous  membrane  is  fully  as  capable 
as  the  ovum  itself  of  intercepting  all  contact  between  the  seminal 
principle  of  the  male  and  that  of  the  female.  To  conclude,  super- 
foetation may  take  place  ;  1 .  In  the  case  of  extra-uterine  pregnancy  5 
2.  In  that  of  a  double  uterus ;  3.  Where  a  woman  has  had  com- 
merce with  two  different  men  on  the  same  day,  or  even  at  short  in- 
tervals with  the  same  man  ;  4.  and  lastly,  While  the  uterine  cavity  is 
not  filled  with  any  substance,  and  the  orifices  of  the  tubes  remain 
perforate. 


•SECTION  2. 
Functions  of  the  FoBtus. 

§.  I.  Of  the  nourishment  of  the  foetus. 

548.  Few  questions  in  physiology  have  occupied  so  much  of  tho 
attention  of  the  learned,  as  that  of  the  nourishment  of  the  foetus. 
Different  authors  have  by  turns  placed  Its  source  in  the  liquor  amnii 
and  in  the  placenta,  in  the  umbilical  vesicle  and  in  the  allantois,  in 
the  gelatine  of  the  cord,  and  in  the  caducous  membrane. 

649.  What  I  have  elsewhere  (410)  said  of  the  anhistous  membrane 
and  its  fluid,  seems  to  me  to  prove  at  least  that  that  tunic  cannot 
concur  in  the  development  of  the  ovum  longer  than  during  the  first 
fortnight  of  its  existence  :  if  Chaussier  and  some  others  have  enter- 
tained a  different  opinion,  it  is  because  they  had  acquired  false  nO" 
lions  concerning  the  caduca,  and  its  nature. 

560.  The  gelatine  of  the  cord,  which,  by  Warthon,  Rouhault, 
Lobstein  and  B6clard,  has  been  supposed  to  play  a  part  in  the 
matter,  has  no  more  to  do  with  it  than  the  caduca,  and  it  is  not  true 
that  it  becomes  loss  abundant  in  quantity  as  the  foetus  grows  larger. 

The  idea  of  making  the  foetus  live  upon  the  fluid  with  whicli  it  is 
surrounded,  is  the  most  ancient  of  all,  and  apparently  the  most  na- 
tural ;  it  gives  rise  to  two  very  distinct  theories  ;  by  one  the  water 
of  tho  amnios  is  supposed  to  be  swallowed  and  digested  ;  according 
to  the  other  it  is  absorbed  in  various  ways. 

661.  In  order  (o  prove  that  the  loatcr  of  the  amnios  serves  for  the 
nourishment  of  the  foetus,  the  old  writers,  particularly  Harvey  and 
Diemcrbroeck,  have  treated  at  great  length  on  its  nutritious  qualities, 
and  on  the  lactescent  matter  wljich  in  their  opinion  it  always  con- 
tains ;  later  authors  have  relied  upon  the  assertion  that  small  animala 


NOtJRISHMENT  OF  THE  FffiTUS.  213 

plunged  in  it  live  longer  than  they  do  when  plunged  in  common 
water  ;  on  its  being  more  abundant  and  fuller  of  nutritive  principles, 
in  proportion  as  pregnancy  is  less  advanced ;  on  the  diminished 
power  of  absorption  in  the  cutaneous  surface  of  the  foetus,  as  it  ap- 
proaches nearer  to  the  full  term  ;  and  on  certain  cases  of  foetuses 
being  born  alive  without  any  umbilical  cord. 

552.  Without  stopping  to  refute  these  various  propositions  one 
by  one,  it  may  be  remarked  that  previously  to  drawing  practical 
consequences  from  them,  their  correctness  should  have  b<;2n  ascer- 
tained :  but  it  has  never  been  proved  that  the  liquor  amnii  is  more 
nutritious  at  the  beginning  than  at  the  close  of  pregnancy  ;  or  that 
the  foetus  absorbs  more  at  one  time  than  another.  As  to  the  ob- 
servations of  Van-der-Wiell,  of  Dennis  and  Littre,  on  the  absence 
of  the  umbilical  cord,  and  on  the  rupture  and  cicatrization  of  its 
divided  extremities,  they  are  too  improbable,  and  accompanied  with 
details  far  too  vague  for  them  to  deserve  the  least  credit. 

Nothing,  positively  nothing,  warrants  our  believing  with  Alcmaeon, 
Boerhaave,  Buflbn,  and  Van-den-Bosch,  that  the  waters  are  taken 
up  by  the  cutaneous  surface.  The  last  author,  it  is  true,  tells  us  he 
saw  the  lymphatic  vessels  full  of  a  fluid  resembling  the  water  of  the 
amnios,  and  that  they  became  fuller  in  the  limb  of  a  cow's  foetus, 
strongly  bound  round  with  a  ligature  and  plunged  in  the  liquor  of 
the  membranes  ;  but  even  admitting  the  experiment  to  be  correct, 
what  conclusion  can  we  draw  from  it  ?  Are  not  the  lymphatic  ves- 
sels habitually  filled  with  seros'ity  ?"  l)o  they  ever  fail  to  become- 
distended  when  a  mechanical  obstruction  prevents  the  free  passage 
of  the  blood  through  a  part,  or  the  whole  of  a  limb  ? 

553.  Founding  on  the  opinion  of  Hippocrates,  of  Harvey,  Rud- 
beck,  &c.  and  on  some  facts  of  his  own,  Diemerbroeck  maintains 
that  the  foetus  is  nourished  by  the  mouth.  His  reasons  are,  *hat  the 
child's  stomach  is  always  filled  with  a  lacteous  matter ;  that  there 
are  excrements  in  its  bowels  ;  that  immediately  after  birth,  or  pre- 
viously to  sucking,  it  frequently  vomits  a  whitish  fluid  ;  that  it  sucks 
a  finger  if  put  into  its  mouth,  even  while  still  within  the  sexual  or- 
gans ;  and  that  its  stomach  would  not  be  able  to  perform  its  diges- 
tive function  immediately  after  parturition,  if  it  were  not  previously 
accustomed  to  it.  If  asked  whence  the  foetus  derives  this  nourish- 
ment, he  answers  that  it  is  at  first  from  the  seminal  fluid,  and  sub- 
sequently from  the  lacteous  juice  contained  in  the  amnios. 

Haller,  Darwin,  &:.c.  add  to  the  reasons  of  Diemerbroeck  and 
La  Courvee,  that  the  amniotic  liquid  has  been  found  in  the  stomachs 
of  many  foetuses ;  that  in  a  pregnant  cow  that  had  been  frozen,  Hcistor 
found  tlie  mouth,  oesophagus  and  stomach  of  the  foetus  filled  with  an 


214 


THE  F(ETUS. 


icicle  which  was  continuous  with  the  waters ;  that  many  observers  have 
met  with  silky  hairs  in  the  meconium,  and  they  conclude  that  all  these 
matters  could  not  have  got  into  the  digestive  passages  by  any  other 
means  than  deglutition. 

More  recently,  this  opinion  has  been  strengthened  by  the  case  of 
a  fcetus  in  which  the  bowel  was  completely  divided  near  the  cascum, 
and  contained  meconium  in  the  portion  connected  with  the  stomach, 
while  the  Jarger  intestine  was  almost  completely  obliterated  •,  by 
another  ocase  mentioned  by  M.  Dubois,  in  which  the  alimentary 
canal  being  contracted  near  the  pylorus,  contained  meconium  only 
in  the  part  above  the  contraction  ;  and  lastly,  by  the  fact  that  Be- 
clard  having  coloured  the  liquor  amnii  with  ink,  in  a  bitch  that  he 
experimented  on,  found  some  of  it  in  the  oesophagus  and  stomach 
of  the  young. 

554.  None  of  these  proofs  are  conclusive ;  most  of  them  do  not 
even  deserve  to  be  seriously  combated.  The  presence  of  hairs  in 
the  intestines  might,  in  fact,  be  explained  in  another  way  ;  but  the 
cases  of  that  kind  that  have  been  reported  are  far  from  authentic. 
To  the  facts  noticed  by  MM.  Desgranges  and  Dubois,  may  be  op- 
posed one  published  by  M.  Piet,  and  in  which  the  intestine,  though 
separated  from  the  stomach,  is  said  to  have  been,  nevertheless,  filled 
with  meconium.  I  have  myself  dissected  a  foetus,  at  full  term,  whose 
oesophagus  upon  reaching  the  diaphragm  ended  in  a  completely  im- 
pervious blind  sac,  notwithstanding  which  its  colon  was  full  of  me- 
conium. While  enclosed  in  the  membranes,  the  mouth  of  the  foetus 
is  closely  shut,  at  least  until  a  pretty  advanced  stage  of  pregnancy ; 
to  swallow,  either  by  suction  or  deglutition,  it  should  be  able  to  per- 
form the  motions  of  inspiration  and  expiration,  of  elevation  and  de- 
pression of  the  larynx.  Acephalous  and  astomatous  foetuses,  and  those 
which -come  into  the  world  with  all  the  openings  of  the  mucous 
membranes  occluded,  are  not  on  that  account  less  completely  de- 
veloped, and  tlieir  alimentary  canal,  according  to  the  reports  of 
certain  observers,  does  not  contain  loss  of  meconium  or  of  hairs. 
It  docs  not  necessarily  follow  from  the  circumstance  that  liquor 
amnii  has  been  found  in  the  stomach,  that  the  foetus  swallows  and 
is  nourished  by  it ;  would  it  be  right  to  infer  that  a  swimmer  natu- 
rally drinks  water,  because  wc  find  some  of  it  in  the  stomachs  of 
drowned  persons?  Finally,  ought  it  not  to  be  enough  to  decide  for 
over  the  question  as  to  the  nutritive  properties  of  the  liquor  amnii, 
to  observe,  that  Bartholin  and  M.  Morlanne  have  seen  the  foetus 
continue  to  live  in  Ihc.  womb  more  than  a  month  aRer  the  complete 
evacuation  of  tlio  waters. 

555.  It  is  therefore  superfluous  to  inquire  whether  the  water  of 


NOURISHMENT  OF  THE  F(ETUS.  j?15 

the  amnios,  after  passing  into  the  intestines,  is  simply  absorbed  from 
them,  as  was  thought  by  La  Courvee  to  be  the  case,  or  whether,  as 
Diemerbroeck,  Boerhaave  and  others  pretend,  it  must  undergo  a 
previous  digestion  in  those  organs ;  neither  is  it  necessary  to  refute 
M.  Lobstein,  who  is  not  far  from  making  it  pass  in,  partly,  by  the 
genital  organs  of  the  foetus ;  nor  Osiander  and  Muller,  who  make 
out,  that  it  is  absorbed,  then  modified  by  the  breasts,  to  be  subse- 
quently carried  to  the  thymus  gland  and  thoracic  duct ;  nor,  finally, 
Schurigius,  David,  Rccderer,  Scheele,  Winslow,  Heroldt,  Bcclard 
and  M.  Geoffroy-Saint-Hilaire,  who  believe  that  it  penetrates  into 
the  trachea  and  bronchia,  in  order  to  be  there  elaborated,  or  serve 
in  some  way  for  the  purposes  of  the  foetal  nutrition. 

Notwithstanding  the  importance  attributed  by  some  writers  to  the 
water  of  the  amnios,  all  the  authors,  except  La  Courvee  and  a  few 
others,  have  confessed  that  the  placenta  performs  the  principal  part 
in  the  nutrition  of  the  foetus,  at  least  during  the  latter  half  of  the 
period  of  gestation. 

There  are  some  who,  with  the  ancients,  suppose  that  the  placenta, 
by  means  of  some  peculiar  lymphatics,  takes  up  a  milky  juice,  a 
real  chyle,  for  the  purpose  of  modifying  or  transmitting  it  to  the 
organs  of  the  foetus. 

666.  Others  have  asserted  that  the  placenta  takes  nothing  from 
the  womb  except  the  oxygen^  that  it  performs  the  functions  of  a  respi- . 
ratory  organ,  that  it  is  the  physiological  lungs  of  the  fcEtus,  and  that  in 
this  view  the  uterine  arteries  represent,  in  some  measure,  the  bronchia 
and  trachea.  In  a  figurativasense  these  assertions  are  not  wholly  with- 
out foundation,  as  I  shall  remark  further  on  ;  but  when  taken  in  a 
literal  sense,  as  they  have  been  by  an  infinite  number  of  physiologists, 
they  become  valueless. 

667.  A  majority  of  writers  maintain  that  the  foetus  is  nourished 
and  developed  by  blood  furnished  to  it  by  the  mother ;  this  is  anotiier 
disputed  point :  is  it  real  blood,  or  only  some  of  its  principles  ? 
Does  it  pass  directly  from  the  vessels  of  the  mother  into  the  circu- 
latory system  of  tiie  foetus  ?  Is  it  merely  poured  into  the  sinuses  of 
the  placenta  ?  Must  it,  or  must  it  not  be  subjected  to  some  prepa- 
ratory elaboration  before  it  reaches  the  placenta  ? 

558.  Galen,  Aristotle,  Vesalius,  Columbus,  Maurocordatus,  Hil- 
danus,  Haller,  and  a  majority  of  accoucheurs  have  been  of  opi- 
nion that  the  blood  passes  directly  from  the  mother  to  the  foetus ; 
the  partisans  of  this  hypothesis,  which  has  been  combated  in  detail 
by  Diemerbroeck,  rely  upon  the  existence  of  vessels  passing  from 
the  womb  to  the  placenta ;  on  this  latter  body  having  been  seen,  as 
by  M.  Ribes,  to  grow  and  live  after  the  expulsion  of  the  fcetus ;  on 


216  THE  F(ETUS. 

the  circumstance,  that  the  detachment  of  the  placenta,  whethei* 
during  pregnancy  or  after  delivery,  always  gives  rise  to  hemorrhagy  5 
that  uterine  hemorrhages  cause  the  fcetus  to  die  exsanguious ;  on 
blood  having  been  observed  to  flow  from  the  placental  end  of  the 
cord  so  as  to  constitute  a  dangerous  hemorrhage  ;  on  M.  Magen- 
die's  having  found  the  odour  of  camphor,  and  the  colouring  matter 
of  madder  in  the  young  of  animals  fed  on  those  substances  ;  on  the 
presence  of  large  orifices  observed  by  various  authors  on  the  internal 
surface  of  the  womb  ;  on  the  fact,  that  the  best  mode  of  arresting 
flooding  is  to  compel  the  womb  to  contract ;  and  above  all,  on  the 
passage  of  various  substances,  when  injected  in  the  uterine  vessels, 
into  the  organs  of  the  foetus. 

659.  None  of  these  reasons  are  demonstrative  ;  we  have  seen, 
above,  that  it  was  necessary  to  imagine  the  existence  of  vascular 
anastomoses  between  the  ovum  and  uterus  :  supposing  the  placenta 
does  sometimes  remain  adherent  to  the  uterus,  and  continues  to  live, 
that  does  not  at  all  prove  that  there  is  a  direct  sanguine  circulation 
from  one  to  the  other  ;  it  is  false  to  say  that  the  detachment  of  the 
placenta  always  occasions  hemorrhage  ;  and  even  if  it  were  true,  it 
would  no  more  militate  in  favour  of  than  against  the  idea  of  im- 
mediate anastomoses,  for  the  blood  in  that  case  may  just  as  well  be 
poured  out  by  exhalation,  as  from  ruptured  vessels.  If  it  be  true 
that  the  heart  and  vessels  of  the  fcetus  are  emptied  of  their  blood 
when  the  mother  dies  with  hemorrhage,  Wrisberg  proves  that  the 
contrary  has  been  very  often  observed  ;  besides,  it  docs  not  follow, 
because  a  child  is  born  anemic  after  a  utQrine  hemorrhage  of  several 
weeks  duration,  that  the  blood  passes  unchanged  to  the  cord,  for  if 
the  woman  be  for  a  long  period  anemic  herself,  it  is  very  natural 
that  the  fruit  of  her  womb  should  also  be  feeble  :  further,  it  seems 
to  be  forgotten  that  many  of  those  hemorrhagies,  as  those  that  depend 
upon  insertion  of  the  placenta  over  the  cervix,  may  come  from  tJie 
vessels  of  the  placenta,  and  consequently,  from  the  fojtus,  as  well  as 
from  the  mother.  When  blood  flows  from  the  uterine  end  of  the 
cord  tiiat  has  just  been  cut,  it  is  not  at  all  because  the  circulation 
continues  to  go  on  from  the  womb  to  the  placenta,  but.it  is  simply 
owing  to  the  contraction  of  the  womb  and  of  the  vessels  of  the 
placenta  itself,  and  of  the  cord  ;  it  is  the  after-birth  disgorging  the 
fluids  it  contained,  and  not  new  blood  coming  from  tlic  woman.  The 
presence  in  the  foetal  organs  of  medicinal  or  alimentary  substances 
taken  by  the  motlier,  is  explained  by  the  laws  of  imbibition  or  by  ab- 
sorption, <iuite  us  satisfactorily,  as  by  an  unintcrru|)ted  continuity  of 
the  vascular  systems  of  the  ovum  and  uterus. 

660.  Still  there  arc  tlie  anatomical  injections  :  they  have  been  m 


NOURISHMENT  OF  THE  FCETUS.  217 

vain  attempted  by  Ruysch,  Haller,  &c.,  but  as  a  thousand  negative 
facts  do  not  destroy  a  single  positive  one,  these  injections  are  con- 
stantly appealed  to  in  support  of  the  hypothesis  in  question. 

561.  M.  Dubois  formerly  exhibited  to  the  Academy  of  Surgery 
a  specimen  he  had  prepared,  and  in  which  the  injection  passed  into 
the  placenta  through  what  he  denominated  the  placento-uterine 
vessels  ;  Chaussier  succeeded  in  impelling  mercury  into  it ;  Beclard 
and  M.  Duges  have  succeeded  with  coloured  oil.  In  the  body  of 
a  pregnant  woman  prepared  for  examination,  M.  Deneux  saw  the 
uterine  sinuses  completely  filled  with  injection,  and  continuing 
without  any  line  of  demarcation  into  the  placental  sinuses,  which 
were  also  filled  with  the  same  m^erial.  Mr  D.  Williams  has  re- 
cently performed  some  experiments,  -from  which  it  appears  that 
linseed  oil,  injected  into  the  aorta  or  hypogastric  arteries,  penetrates 
into  the  organs  of  the  foetus  ;  and  M.  Biancini,  who  has  performed 
experiments  on  one  woman  who  died  whilst  in  labour,  on  another 
who  died  in  a  week  after  delivery,  and  on  a  third  who  died  with 
flooding,  as  also  on  cats,  rabbits  and  cabiais,  assures  us  he  obtained 
the  same  results  with  size  and  with  mercury,  which,  he  thinks, 
answer  better  than  oil :  in  addition  to  the  utero-placental  arteries, 
the  Italian  physiologist  describes  a  set  of  veins  of  a  corresponding 
character. 

662.  But  it  seems  to  me  there  is  a  strange  misconception  of  the 
value  of  such  experiments.  How  happens  it  that  they  have  not 
been  regarded  as  but  little  applicable  to  the  explanation  of  what 
takes  place  in  the  living  female.  How  long  has  the  passage  of 
foreign  matters  from  one  vessel  to  another  proved  incontestably 
that  the  same  thing  takes  place  with  the  natural  fluids  during  the 
life  of  the  individual  ? 

663.  When  a  pretty  fine  injection  is  thrown  into  the  arteries  of 
the  belly,  the  matter  readily  escapes  from  the  internal  substance  of 
the  intestines  ;  when  thrown  into  the  vena  portse,  it  returns  not  only 
by  the  veins  and  the  hepatic  artery,  but  also  through  the  excretory 
bile  ducts  ;  when  thrown  into  the  emulgent  artery,  it  soon  pasees 
into  the  emulgent  vein,  as  also  into  the  pelvis  of  the  kidney,  and  the 
ureter.  Notwithstanding  the  above,  we  do  not  conclude  that  the 
blood  during  life  is  continually  transuding  into  the  alimentary  canal, 
nor  that  it  passes  from  the  vessels  of  the  liver  into  the  hepatic  ducts, 
or  from  the  kidneys  into  the  tubuli  uriniferi  and  ureters  ;  the  oil, 
glue  and  mercury  employed  by  Chaussier,  and  Messrs  Wilkams  and 
Biancini,  are  of  too  penetrating  a  nature  not  to  go  wherever  it 
may  be  desired  to  send  them  ;  but  whether  the  passage  in  question 

2C 


218 


THE  FCETUS. 


does  or  does  not  take  place,  it  will  certainly  never  serve  to  resolve 
the  problem  at  issue. 

564.  Hanter  and  several  modern  physiologists  expect  to  get  rid 
of  the  difficulty  by  admitting  that  the  uterine  sinuses  pour  their 
blood  into  the  sinuses,  or  interlobular  anfractuosities  of  the  placenta, 
whence  it  is  subsequently  taken  up  by  the  numerous  capillary  orifi- 
ces of  the  umbilical  vein.  This  hypothesis,  although  more  specious 
and  rational  than  the  preceding  one,  is  not  therefore  less  difficult 
to  adopt ;  without  referring  on  this  point  to  what  I  have  already  said 
(478)  concerning  these  pretended  sinuses  and  their  adaptation,  I 
remark  :  1 .  That  such  an  arrangement  cannot  be  admitted  to  take 
place  in  extra-uterine  pregnancies  ;  2.  That  until  the  second  or 
third  month,  the  placenta  being  composed  of  merely  agglomerated 
filaments,  there  can  be  no  sinuses  betwixt  its  lobules  ;  3.  That  a 
placenta,  although  attached  upon  a  fibrous  polypus,  or  upon  some 
indurated  portion  of  the  uterus,  has  nevertheless  been  found  to  sup- 
ply all  the  materials  required  for  the  foetal  nutrition ;  4.  That  I 
have  seen  the  uterine  surface  of  the  afterbirth  hard,  coriaceous, 
and  without  any  orifice  throughout  almost  its  whole  extent,  in  women 
who  were  delivered  of  children  that,  although  weak  indeed,  were 
nevertheless  living  ;  5.  That  the  large  vessels  of  the  womb,  said  to 
be  continuous  with  the  vessels  of  the  placenta,  are,  by  the  very  parti- 
sans of  the  doctrine,  admitted  to  be  veins  ;  G.  That  the  uterine  veins 
being,  like  the  veins  of  all  other  parts  of  the  body,  the  vessels  of  a 
convergent  and  notof  a  divergent  circulation,  as  they  should^be,  con- 
sistently with  the  views  of  that  party,  it  follows  that  they  are  pleased 
to  get  venous  and  not  arterial  blood  from  the  mother  into  the  pla- 
centa. 

566.  Should  it  be  insisted  upon  that  the  fojtus  receives  completely 
elaborated  blood  From  the  mother,  it  could  only  be  possible,  at  the 
utmost,  to  say,  as  indeed  it  has  been  said,  that  that  fluid  enters  the 
placenta  through  simple  pores,  by  a  sort  of  imbibition  which  might 
be  explained  by  a  mere  contiguity  of  surfaces.  To  this  1  can  only 
object  that  the  blood,  as  such,  does  not  appear  to  pass  in  any  way 
into  the  ovum.  It  certainly  docs  not  pass  there  at  least  in  the  early 
periods  ;  for  the  villous  portions  of  the  chorion  do  not  contain  ves- 
sels until  pretty  late,  and  besides,  its  filaments  arc  never  hollow  quite 
to  their  extremitics(476).  On  the  other  hand,  botii  Autcnrcith's 
and  my  own  experiments  demonstrate  that  tlio  blood  of  the  foetus 
does  not  present  the  same  aspect  as  that  of  the  mother  :  it  is  at 
first  of  a  rose  colour  ;  it  then  becomes  redder,  then  blacker,  and 
does  not  exhibit  any  dificrcnce  of  colour  in  the  veins  and  arteries. 
Ticdcmann  and  others  have  found  that  it  contains  a  much  larger 


•  NOURISHMENT  OF  THE  FCETUS.  219 

proportion  of  serum  than  the  blood  of  an  adult,  and  is  less  coagu- 
bble  ;  in  fine,  every  thing  proves  that  its  chemical  composition  is 
Tery  different  from  that  of  the  mother.  Even  although  chemistry 
had  not  been  able  to  ascertain  for  us  these  differences,  would  it  be 
right  to  believe  that  this  fluid  need  not  have,  hke  our  aliment,  a  due 
relation  to  the  period  of  our  life,  whether  extra  or  intra-uterine,  and 
that  the  blood  of  an  adult  woman  would  not  be,  in  some  sort,  a  poison 
to  so  frail  and  delicate  a  being  as  the  embryo,  or  fcetus  ?  Were  it 
wotth  while  to  insist  upon  tliis  point,  I  might  add  tliat  according  to 
the  microscopical  observations  of  MM.  Prevost  and  Dumas,  the 
blood-globules  are  so  small  in  the  fcetus,  that  it  would  be  impos- 
sible for  those  of  the  mother  to  pass  through  the  same  canals  or 
same  orifices  without  destroying  the  equilibrium  of  all  the  functions, 
and  producing  sudden  death. 

If,  therefore,  the  blood  is  poured  into  the  caverns  of  the  placenta, 
or  taken  up  by  the  pores  of  that  organ,  it  must  at  least  undergo 
some  elaboration,  some  important  modification  before  it  reaches  the 
umbilical  vein  ;  but  what  is  the  nature  of  that  modification  ?  I 
know  not. 

666.  In  conclusion,  the  nourishment  of  the  ovum  is  dependent 
on  various  sources ;  at  first  it  is  a  mere  vegetable,  which  imbibes 
the  surrounding  moisture.  The  villi  of  its  superficies,  real  cellular 
spongioles,  acquire,  in  the  tube  or  in  the  womb,  the  nutritive  princi- 
ples required  for  the  development  of  the  embryo  vesicles ;  after 
which  the  embryo  is  nourished  after  the  manner  of  the  chick  in  ovo, 
or  rather  like  the  young  plant,  wiiich  is  at  first  evolved  at  the  ex- 
pense of  principles  contained  in  its  cotyledons.  It  gradually  ex- 
hausts the  vitelline  matter  contained  in  the  umbilical  vesicle ;  the 
emulsive  substance  of  the  reticulated  body  or  allantois  is  also  gradu- 
ally absorbed.  It  reaches  the  end  of  the  second  month  ;  the  ves- 
sels of  the  cord  are  formed  ;  the  placenta  soon  begins  to  show  itself, 
and  suffices  to  keep  up  the  evolution  of  the  fcetus  ;  by  its  contact, 
the  spongy  cake  takes  up  from  the  womb  the  elements  of  repara- 
tion, and  operate;  on  them,  forming  a  fluid  more  or  less  analogous  to 
blood,  which  is  then  absorbed  by  the  radicles  of  the  umbilical  vein. 
The  placenta  absorbs  in  the  uterus,  so  as  to  form  the  fluids  of  the 
foetus,  as  the  liver,  the  kidney,  the  seminal  gland,  &.c.  take  up  from 
their  own  vessels  the  materials  from  which  to  form  the  bile,  the 
urine,  the  prolific  liquor,  &.c.  ;  as  trees  and  plants  absorb  from  the 
ground  the  principles  of  the  numerous  compounds  they  contain  : 
and  I  see  nothing  in  all  these  actions  very  diflicult  of  comprehen- 
sion. 


220  THE  F(ETUS. 

§.  II.  Circulation  of  the  foetus. 

Whatever  may  be  the  manner  in  which  blood  or  other  fluids  reach 
the  placenta,  it  is,  notwithstanding,  necessary  for  them  afterwards  to 
traverse  the  various  organs  of  the  fcEtus  for  their  nourishment : 
however,  their  circulation  does  not  in  all  respects  resemble  that 
which  takes  place  after  the  birth  of  the  child.  ^ 

667.  In  the  adult,  the  septum  that  divides  the  two  auricles  of  the 
heart  is  complete,  and  separates  them  from  each  other  perfectly  ;  in 
the  foetus,  on  the  contrary,  this  septum  has  an  opening  through  it, 
called  the  foramen  ovale,  which  is  largest  in  the  early  stages  of 
pregnancy.  Previously  to  birth,  instead  of  two  large  trunks,  the 
pulmonary  artery  furnishes  only  two  small  branches  to  the  lungs  ; 
but  it  is  prolonged,  under  the  name  of  the  arterial  canal  (ductus 
arteriosus)  as  far  as  to  the  aorta,  into  which  it  opens  below  the  left 
subclavian  artery.  The  hypogastric  branches  of  the  primitive  ihacs 
send  only  small  branches  to  the  pelvic  organs,  which  are  as  yet 
scarcely  developed  ;  but  they  rise  along  the  sides  of  the  bladder  and 
urachus,  under  the  name  of  umbilical  arteries.^  and  proceed  to  the 
umbilical  ring  and  to  the  cord.  Unlike  the  aduU,  the  fojtus  also 
has  an  umbilical  vein,  which,  upon  entering  into  the  abdomen,  pro- 
ceeds backwards  and  upwards,  and  somewhat  from  left  to  right,  so 
as  to  pass  into  the  longitudinal  fissure  of  the  liver,  through  which  it 
passes,  giving  off  here  and  there  a  branch  to  the  right  and  left  lobes 
of  the  liver.  Having  reached  the  under  surface  of  the  liver  in  the 
transverse  fissure,  the  umbilical  vein  divides  into  two  trunks  :  one, 
which  is  called  the  venous  canal  {ductus  venosus),  and  which,  Hke 
the  ductus  arteriosus,  grows  smaller  and  smaller  as  the  term  of  gesta- 
tion approaches,  appears  to  be  a  continuation  of  the  primitive  vein, 
and  proceeds  to  open  into  the  trunk  of  the  vena  cava,  below  the  dia- 
phragm ;  the  other,  which  constitutes  the  right  branch  of  the  vena 
portaj,  penetrates  into  the  liver,  where  it  at  length  anastomoses  with 
the  radicles  of  the  hepatic  veins,  which,  as  in  the  adult,  proceed  to 
open  into  the  vena  cava  a  little  above  the  ductus  venosus. 

5G8.  Course  of  the  blood.  From  the  above  arrangement  of  the 
circulatory  organs,  it  is  evident  that  the  course  of  the  fluids  must  be 
much  more  complicated  tlian  in  the  adult.  From  the  smaller  branches 
of  the  umbilical  vein,  the  blood  passes  into  the  larger  ones,  and  soon 
afterwards  into  the  great  trunk  of  that  vessel,  it  then  passes  along  the 
cord  through  the  umbilicus,  and  divides  beneath  the  liver  into  two  prin- 
cipal currents,  one  of  which  follows  the  venous  canal  so  as  to  go  and  be 
mixed  with  the  blood  of  the  inferior  cava,  while  the  other  proceeds 
along  the  umbilical  branch  of  the  vena  porta;,  to  be  ramified  in  the 
right  lobe  of  the  liver,  and  taken  up  by  the  hepatic  veins,  which  pour 


CIRCULATION  OF  THE  FOETUS.  221 

it  into  the  trunk  of  the  cava  as  it  passes  through  the  diaphragm. 
There  it  forms  three  columns  ;  that  of  the  venous  canal,  that  of  the 
hepatic  veins,  and  that  which  is  brought  by  the  cava  from  the  lower 
half  of  the  body,  which  unite,  and  together  enter  the  right  auricle, 
thence  passing  through  the  foramen  ovale  into  the  left  auricle ;  from 
the  latter,  the  blood  falls  into  the  corresponding  ventricle,  which 
forces  it  along  the  aorta  towards  all  parts  of  the  body,  but  chiefly  to 
the  head  and  upper  extremities,  by  means  of  the  brachio-cephalic 
trunk,  the  left  carotid,  and  the  subclavian. 

569.  After  losing  among  the  tissues  the  nutritive  principles  with 
which  it  was  charged,  the  blood  is  brought  back  by  the  jugular  and  the 
axillary  veins  to  the  subclavians,  and  thence  to  the  superior  cava, 
which  also  receives  that  of  the  azygos  ;  the  superior  cava  carries  it  to 
the  right  auricle,  the  auricle  to  the  right  ventricle,  and  the  latter  to  the 
pulmonary  artery,  which  directs  only  two  small  columns  of  it  to  the 
lungs,  and  causes  the  rest  of  it  to  pass  through  the  arterial  duct  to 
the  descending  aorta,  where  it  meets  with  a  part  of  what  the  left 
ventricle  Jiad  already  expelled.  That  portion  which  reaches  the 
primitive  iliacs  is  in  part  distributed  to  the  lower  extremities  by  the 
external  iliacs ;  but  by  far  the  largest  portion  of  it  returns  along  the 
umbilical  arteries,  through  the  cord,  and  at  last  to  the  placenta, 
from  whence  it  set  out. 

570.  In  the  heart.  Haller,  Wolf,  Sabattier,  MM.  Portal,  Riche- 
rand,  &c.  supposed  that  the  blood  of  the  two  venae  cavas  does  not 
mix  at  all  in  the  right  auricle,  that  that  of  the  ascending  or  inferior 
cava  passes  entirely  to  the  left,  and  that  of  the  superior  cava  entirely 
into  the  right  ventricle. 

571.  Bichat  was  opposed  to  this  view  of  the  subject,  and  M. 
Magendie  does  not  adopt  it ;  it  is  diflicult,  say  they,  to  understand 
how  two  columns  of  fluid  can  pass  into  the  same  cavity  without  being 
mixed  together  ;  the  two  auricles  contract  simultaneously,  and  not 
one  after  the  other  ;  it  is  not  probable  that  the  vivified  blood  fur- 
nished by  the  umbilical  vein  passes  wholly  to  the  superior  half  of 
the  body,  and  that  the  venous  blood  alone  is  expended  in  the  re- 
maining moiety.  But  seeing  that  the  vena  cava  inferior,  surmounted 
by  the  Eustachian  valve,  seems  to  be  continuous  with  the  foramen 
ovale,  rather  than  to  open  merely  into  the  right  auricle,, and  that  the 
cava  superior  opens  opposite  to  the  orifice  of  the  right  ventricle,  and 
on  a  plane  which  is  rather  in  front  of  the  inferior  cava,  it  appears  to 
me  we  may  conceive  that  the  blood  of  the  two  vessels  may  really 
pass  into  the  left  auricle  and  left  ventricle,  without  necessarily  mixing. 
The  simultaneous  contraction  of  the  auricles  does  not  seem  to  oppose 
this  transfer ;  the  blood  of  the  inferior  cava  does  not  pass  through 


323  THE  FffiTUS. 

the  foramen  ovale  during  the  contraction  of  the  organ,  nor  does  that 
of  the  superior  cava  get  into  the  ventricle  during  that  action  ;  if  they 
are  both  full  of  fluid  at  the  moment  the  systole  commences,  what  is 
to  prevent  their  passing"  it,  without  mixing,  into  the  corresponding 
cardiac  ventricle  ? 

I  believe,  therefore,  that  Sabattier's  theory  is  the  best  founded, 
and  that  only  a  very  small  quantity  of  the  blood  poured  into  the  right 
auricle  by  the  two  cava^  respectively  is  mixed  there. 

572.  However,  it  must  not  be  supposed  that  the  head  and  limbs 
receive  none  but  the  blood  brought  to  the  heart  by  the  umbilical 
vein  and  its  branches,  nor  that  the  abdomen  and  inferior  extremities 
are  nourished  only  by  the  blood  of  the  superior  cava :  on  the  one 
hand,  it  would  be  absurd  to  suppose  that  that  which  is  driven  by  the 
left  ventricle  into  the  arch  of  the  aorta,  passes  on  into  the  carotid 
and  subclavian  arteries,  without  some  of  it  descending  along  the 
thoracic  aorta ;  and  on  the  other,  even  were  that  the  case,  this  blood 
is  no  longer  as  pure  as  it  was  on  leaving  the  placenta,  for  it  is  neces- 
sarily mixed  with  the  venous  blood  of  the  lower  extremities  and 
abdomen.  Further,  the  blood  that  passes  along  the  aorta  descen- 
dens  is  not  merely  the  blood  of  the  ductus  arteriosus^  but  with  it 
also  is  mixed  that  of  the  inferior  cava. 

573.  In  the  placenta.  Some  persons  have  supposed  that  the  blood 
brought  back  by  the  umbilical  arteries  is  taken  up  by  the  uterine 
veins,  and  proceeds  to  be  revivified  in  the  lungs  of  the  mother,  before 
returning  to  the  ovum ;  others  have  thought  that  'only  a  portion  of  it 
is  absorbed,  while  the  rest  passes  immediately  into  the  capillaries  of 
the  vein  ;  that  there  is  in  some  sense  two  circulations,  one  great  ciV' 
culation,  completely  under  the  influence  of  the  heart  and  lungs  of 
the  mother,  and  one  lesser  circulation,  the  only  one  really  belonging 
to  the  fcEtus.  What  has  been  said  above  will,  I  think,  sufllce  to 
cause  such  opinions  to  be  appreciated  at  their  just  value  ;  I  shall 
content  myself  with  remarking  here,  that  in  order  to  admit  of  what 
is  called  a  great  circulation,  the  pulsations  of  the  foetal  must  be  iso- 
chronous with  those  of  the  maternal  heart.  But  the  mode  of  aus- 
cultation introduced  by  M.  Kergaradec  proves,  as  it  had  indeed 
been  before  remarked  by  Dicmerbrocck,  that  thrre  is  no  such  iso- 
chronism,  aqd  that  tjie  foetal  licart  bcUts  one  half  oftencr  than  that 
of  a  majority  of  women. 

574.  If  it  were  true  that  tlic  blood  of  tiio  unii)ilical  arteries  is 
poured,  as  pretended,  into  tlie  placental  sinuses,  it  evidently  would 
mix  with  that  of  tlic  uterine  arteries,  which,  according  to  the  same 
theory,  is  also  depositfd  therein ;  if  so,  we  must  be  compelled  to 
believe  that  the  absorbing  mouths  of  the  umbilical  veins  have  the 


CIRCULATION  OF  THE  FCETUS.  223 

faculty  of  choosing  the  arterial  blood  out  of  this  mixture,  while  the 
uterine  veins  take  up  only  venous  blood :  such  an  idea  is  not  to  be 
defended.  Besides,  as  the  matter  of  injection,  even  the  coarsest, 
passes  with  an  astonishing  facility  from  the  arteries  to  the  veins  of 
tiie  placenta  without  being  effused  on  its  uterine  surface,  it  appears 
to  me  that  we  may  with  certaijity  conclude  that  the  blood  of  the  foetus 
is  not  takenk-^  by  the  womb. 

575.  This  does  not,  however,  imply  that  the  blood  from  the  arte- 
ries re-enters  the  umbilical  vein  without  undergoing  any  changes ; 
but  rather,  only  that  these  changes,  purely  molecular,  arc  effected 
in  the  placenta  itself  This  elaboration  is  not  the  less  undeniable 
because  its  essence  is  not  understood.  It  may  be  compared  to  that 
which  is  effected  after  birth  in  the  general  capillary  system ;  and  to 
that  which  occurs  in  the  secretory  organs,  and  in  the  lungs  themselves. 
The  fluids  of  the  ovum  are  brought  into  contact  with  those  of  the 
mother,  and  at  that  instant  a  change  of  principles  is  effected  between 
them,  as  takes  place  in  the  bronchia  between  the  atmospheric  air 
and  the  venous  blood  of  the  lungs  ;  but  here  all  our  information  is 
limited. 

576.  Ill  the  liver.  The  truly  enormous  size  of  the  liver  during 
the  intra-uterine  life,  long  ago  gave  rise  to  the  supposition  that  it 
was  an  organ  of  hematosis,  or  that  it  modified  the  blood  in  some 
manner.  M.  Lobstein  appears  to  be  still  of  this  opinion.  Fourcroy 
says  that  if  this  modification  does  take  place,  it  must  consist  in  a 
kind  of  decarbonization  and  disbydrogenization.  More  recently 
still,  MM.  Prevost  and  Dumas  thought  they  had  observed  that  the 
first  blood  globules  of  the  foetus  appeared  in  the  liver.  If,  says  M. 
Geofi'roy  de  Saint  Hilaire,  the  liver  receives  so  great  a  quantity,  and 
exhibits  such  a  considerable  size,  it  is,  that  it  may  secrete  a  great 
quantity  of  bile,  which,  being  poured  into  the  small  intestine,  occa- 
sions th*  formation  therein  of  an  abundant  quantity  of  mucus  that 
the  fcctus  digests,  and  on  which  it  grows.  Finally,  Dr  Lee  of  Lon- 
don has  just  performed  some  new  experiments,  whence  it  results, 
that  the  use  of  the  liver  is  to  secrete  an  abundant  albuminous  and  nu- 
tritive matter;  that  this  substance  fills  the  hepatic  ducts,  the  duodenum 
and  snxall  intestines  ;  while  in  the  stomach  we  find  only  an  acid  fluid, 
and  meconium  in  the  large  intestines. 

577.  Of  these  different  uses,  not  one  is  matter  of  demonstration  ; 
those  indicated  by  Fourcroy,  M.  Lobstein  and  M.  Geoffrey,  are  even 
based  upon  mere  suppositions,  that  are  easy  to  overthrow  ;  and 
although  the  theory  of  Dr  Lee  and  Dr  Prout  is  supported  by  some 
facts,  it  seems  to  be  the  dictate  of  prudence  that  we  should  wait 


r 


224  THE  FOETUS: 

before  we  decide,  and  admit  that  at  present  we  do  not  know  what 
influence  is  exerted  by  the  liver  on  the  fetal  blood. 

§.  III.  Of  the  respiration  of  the  foetus. 

678.  Air  being  indispensable  to  respiration,  it  seems  quite  natural 
that  that  function  should  have  no  existence  in  the  fcetus ;  but  on  the 
other  hand,  as  absorption  of  air  or  oxygen  seems  to  Ire  indispensable 
to  the  maintenance  of  life  in  all  organic  beings,  attempts  have  been 
frequently  made  to  prove  that  all  animals  respire  during  their  foetal 
life. 

679.  As  to  the  human  species,  it  has  been  said  that  the  placenta 
receives  oxygen  from  the  blood  of  the  mother  at  the  same  time  that 
its  own  parts  with  certain  heterogeneous  principles,  as,  for  example, 
a  portion  of  its  serum  :  this  opinion,  which  is  of  an  ancient  date,  has 
been  latterly  defended  by  MM.  Lobstein,  Meckel,  and  MuUer. 

It  is  true,  that  in  order  to  explain  the  changes  undergone  by  the 
blood  in  passing  through  the  placenta,  we  may  compare  that  work 
to  respiration  ;  but  to  accept  such  a  comparison  in  the  very  letter, 
would  be  most  strangely  to  wrest  the  analogies.  The  blood  which 
re-enters  the  umbilical  vein  is  doubtless  modified,  but  it  is  not  red- 
der than  it  is  in  the  arteries ;  the  change  it  has  just  experienced 
does  not  therefore  in  the  least  resemble  that  which  occurs  in  its 
passage  from  the  pulmonary  arteries  into  the  pulmonary  veins  of  the 
adult. 

680.  Some  other  persons,  and  particularly  M.  Geoffroy  de  Saint 
Hilaire,  have  admitted  that  the  fcetus  absorbs  air  or  a  vivifying  gas 
from  the  whole  surface  of  its  body,  by  a  kind  of  tracheae  like  those 
of  insects,  or  even  by  the  pulmonary  passages,  which  might  in  such 
case  be  compared  to  branchize,  and  that  it  respires  after  the 
manner  of  fishes  ;  but  I  have  already  stated  that  the  gas  obtained 
by  M.  Lassaigne  in  his  first  experiments  was  only  a  compound  of 
carbonic  acid  and  azote. 

681.  Some,  however,  have  persisted  in  maintaining  that  the  lung 
exerts  a  certain  action  on  the  water  of  the  amnios  ;  that  it  separates 
air  or  some  other  principle  from  it ;  in  a  word,  that  it  exercises  a 
sort  of  respiration  :  on  tliis  subject  reliance  has  been  placed  on 
some  researches  made  in  Denmark  by  Scheele,  Wiborg,  Winslow, 
llcroldt,  &c.  ;  experiments  that  tend  to  prove  that  the  licjuor  amnii 
fills  the  trachea  and  bronchia  of  the  foetus  ;  on  those  of  Beclard, 
who  saw  the  same  thing  ;  and  further,  that  the  young  of  a  bitch,  still 
enclosed  in  the  membranes,  executed  the  motions  of  dilating  and 
contracting  the  alae  nasi,  and  of  the  chest ;  lastly,  on  the  fact  that 


RESPIRATION  OF  THE  F(ETUS.  225 

the  foetus  has  on  more  than  one  occasion  been  heard  to  cry  while  in 
the  mother's  \romb. 

582.  But  It  has  been  seen,  farther  back,  what  ought  to  be  thought 
of  the  presence  of  liquor  amnii  in  the  gastric  or  pulmonary  passages 
of  the  dead  foetuses.  De  BufTon  and  Autenreith,  who  got  the  foetuses 
of  animals  to  live  in  that  fluid  ;  Wrisberg  and  Osiander,  who  have 
both  seen  the  human  foetus  live  ten  and  fifteen  minutes  out  of  the 
womb  with  the  membranes  unruptured,  did  not  see  the  respiratory 
movement  mentioned  by  Beclard  ;  I  too  had  an  opportunity,  in  1825, 
of  witnessing  a  fact  that  was  very  curious,  and  well  adapted  to 
illustrate  this  point :  a  woman  at  the  hospital  de  Perfectionnement, 
and  who  said  she  was  six  complete  months  pregnant,  was  suddenly 
delivered  at  five  o'clock  in  the  morning  of  the  23d  of  August ;  the 
ovum,  which  came  away  whole,  was  received  by  M.  Lafond,  a  resident 
student  at  the  hospital.  The  specimen  was  immediately  brought  to 
me,  and  I  placed  it  in  a  large  bowl  of  tepid  water.  The  foetus  did 
not  appear  to  be  of  more  than  five  months  and  a  half ;  1  left  the 
membranes  whole  ;  I  carefully  examined  the  nose,  the  mouth,  the 
abdomen  and  thorax  of  the  foetus,  which  continued  tp  live  in  this  way 
for  thirty-six  minutes,  but  I  discovered  no  motion  in  the  thorax, 
except  the  slight  throbbing  occasioned  by  the  action  of  the  heart. 
We  were  also  able  to  convince  ourselves  that  the  water  of  the  amnios 
had  penetrated  neither  into  the  trachea  nor  the  stomach. 

583.  Uterine  vagitus.  As  to  the  cries  generally  known  under 
the  title  of  vagitus  uterinus,  examples  of  it  may  be  found  in  Albert 
Legrand,  Libavius,  Solinus,  Camerarius,  Sennertus,  BarthoHn,  Deu- 
singius,  Velthusius,  Boyle,  and  Needham  himself;  but  these  ac- 
counts being  given  only  upon  the  hearsay  of  old  women,  do  not  de- 
serve the  trouble  of  being  repeated.  The  subject  has  come  up 
again  in  our  own  day  :  Osiander  afiirms  that  he  heard  these  cries 
in  two  different  women  ;  M.  Zitterland  cites  an  instance  of  it  which 
he  himself  witnessed,  after  having  taken  all  proper  precautions  to 
avoid  being  deceived ;  MM.  Henri  and  Jobert  have  observed  the 
same  thing  at  Paris,  in  an  incontestable  manner,  in  1825,  according 
to  the  report  of  M.  Marc  ;  M.  Hesse  has  related  a  fifth  case  ;  and 
M.  Lesauvagc  assures  us  that  he  very  distinctly  heard  the  cries  of 
young  puppies  while  still  in  their  mother's  belly. 

584.  When  the  membranes  are  ruptured  and  the  waters  discharg- 
ed, when  the  orifice  is  dilated,  and  the  child's  face  engaged  more  or 
less  deeply  in  the  excavation,  we  may  conceive,  indeed,  that  the  foetus 
might  breathe  and  utter  some  cries  before  its  complete  expulsion  ; 
but  still  the  state  of  compression  and  constraint  of  the  thorax  ren- 
ders the  possibility  of  such  an  occurrence  very  doubtful ;  but  when 

2  D 


226  THE  FOETUS. 

the  ovum  is  entire,  as  in  the  case  given  by  M.  Lesauvage,  the  fact  is 
so  improbable,  that  we  are  not  authorised  to  draw  any  conclusions 
from  it.  • 

It  is  sometimes  so  difficult  to  avoid  all  the  causes  of  error, 
all  subterfuges,  not  to  be  deceived  by  strange  and  unexpected 
noises,  such  for  example  as  are  often  produced  by  air  in  the 
intestines,  that  before  we  admit  as  positive  a  phenomenon  which 
it  is  impossible  to  reconcile  with  the  laws  of  physiology,  the 
same  person  should  have  ascertained  its  existence  repeatedly ;  in 
the  mean  time,  I  may  say  with  Fontenelle,  that,  since  learned  and 
credible  men  have  heard  it,  I  will  believe  it,  but  I  should  not  believe 
it  if  I  had  heard  it  myself. 

685.  Further,  if  the  foetus  really  breathed  ;  if  air  passes  through 
its  lungs,  they  would  be  permeable  and  spongy,  while  at  birth  they 
arc,  as  is  well  known,  quite  compact,  and  as  heavy  as  a  slice  of  mus- 
cular tissue. 

§.  IV.  Of  the  viability  of  the  foetus. 

586.  The  word  viability,  derived  from  ma,  is  employed  in  medi- 
cal jurisprudence  to  express  the  possibility  of  passing  through  the 
various  phases  of  human  life.  To  render  a  child  viable,  it  should 
possess  at  birth  an  aptitude  to  live  independently  of  its  mother ; 
from  this  definition  it  will  be  perceived  that  a  foetus  at  term,  as  has 
been  remarked  by  M.  Billard,  may  be  born  not  viable,  provided  it  be 
affected  with  some  faults  of  conformation,  or  with  certain  diseases, 
as  also  that  a  foetus  may  be  born  viable  although  dead  when  passing 
from  its  mother's  womb. 

At  what  stage  of  pregnancy  is  viability  possible?  Although 
debated  by  accoucheurs  and  physicians  in  all  ages  and  countries,  this 
question  has  continued  until  this  moment  undecided.  The  foetus, 
which  according  to  some  persons  is  viable  at  four  months  and  a  half, 
does  not,  according  to  others,  really  enjoy  viability  until  the  seventh 
month. 

587.  The  law  having  determined  that  a  child  born  before  the  one 
hundred  and  eightieth  day  after  marriage  may,  if  it  is  pronounced  to 
bo  viable,  be  disowned  by  the  husband,  implicitly  declares  that  viabi- 
lity commences  with  the  seventh  month.  As  a  legislative  measure, 
this  decision  is  extremely  wise,  and  could  not  be  more  just ;  but  it 
docs  not  by  any  means  prove  that  a  foetus  is  never  viable  before  the 
end  of  the  sixth  month,  nor  that  it  is  always  so  at  the  commence- 
ment of  the  seventh.  The  determination  as  to  tlic  viability  of  the 
child  ought  to  depend  on  the  degree  of  perfection  attained  by  the 
foetal  organs,  and  not  on  the  stage  of  pregnancy.     But,  aS  the  cvo- 


VIABILITY  OF  THE  FCETUS.  227 

lution  of  the  fcetus  is  not  always  in  the  same  ratio,  it  follows  that  an 
eight  months  fcetus  may  be  less  viable  than  one  of  seven  months. 

588.  Should  we  refer  on  this  head  to  the  cases  related  by  various 
authors,  we  might  have  examples  of  children  that  were  infinitely 
small,  of  some  born  at  four  months  or  four  months  and  a  half,  and 
nevertheless  become  robust  and  vigorous  men.  Who  is  unacquaint- 
ed with  the  history  of  the  celebrated  Fortunio  Liceti,  related  by  Van 
Swieten  ?  His  mother,  frightened  by  the  roughness  of  the  sea  while 
passing  from  Reco  to  Rapallo,  brought  him  into  the  world  before 
the  sixth  month  of  her  pregnancy  ;  he  was  not  bigger  than  a  hand  ; 
his  father  had  recourse  to  the  heat  of  an  oven  to  bring  him  up,  and 
notwithstanding  all  that,  Fortunio  lived  to  be  seventy-nine  years  old. 
An  abortion,  says  Brosset,  was  born  in  1748,  at  the  fifth  month  of 
pregnancy,  and  lived  to  thB  ninth  month,  without  sucking,  without 
producing  any  excretion,  or  performing  any  other  motion,  save  to 
swallow  a  few  drops  of  milk ;  but,  four  months  after  its  birth,  it  sud- 
denly cried,  and  sucked,  and  moved  its  limbs,  so  that  at  sixteen 
months  old  it  was  stronger  than  children  of  that  age  commonly  are. 
To  be  sure,  one  ought  really  to  have  been,  like  Brousset,  a  wit- 
ness to  such  a  miracle  to  be  able  to  believe  it.  Thebesius  also  pre- 
tends to  have  seen  a  foetus,  born  before  the  seventh  month,  which 
could  not  cry  until  the  ninth,  but  which  was  still  very  weak  after  the 
lapse  of  a  year.  Pleissmann  cites  another  such  case,  quite  similar 
to  that  of  Brousset,  except  that  the  foetus  was  born  at  a  more  ad- 
vanced stage  of  the  pregnancy.  The  daughter  of  P.  Soranus,  ac- 
cording to  Cardan,  came  into  the  world  at  the  sixth  month  :  to 
nourish  her  they  were  obliged  to  pour  milk  into  her  mouth  by  means 
of  a  funnel,  which  did  not  prevent  her  from  running  a  long  career*. 
Millot,  who,  in  the  matter  of  proof,  does  not  seem  to  be  very  difii- 
cult,  speaks  of  a  certain  Julius  Modie,  born  in  the  year  V,  at  five 
months  and  a  half,  and  who  was  so  small  and  weak  that  at  first  he 
could  not  suck  at  all.  This  child,  however,  grew  very  well.  Have 
we  not  also  had,  as  proof  of  anticipated  viability,  the  history  of  the 
famous  Bcbe  de  Nanci,  who  only  weighed  one  pound  at  birth, 
whose  first  cradle  was  a  sabot,  says  the  Count  de  Tressan,  and  of 
which  there  is  a  wax  model  in  the  cabinets  of  the  school  of  Medicine 
at  Paris.  But  I  ask,  what  conclusion  can  we  draw  from  observa- 
tions so  imperfectly  substantiated,  from  facts  encompassed  with  so 
many  marvels,  and  citations  so  improbable. 

*  Spigelius  speaks  of  a  maD  who  was  born  at  the  commencement  of  the  sixth 
month,  and  who  was  obliged  to  be  kept  wrapped  up  in  cottoa  for  more  than  six 
weeks.  Monlus  says  that  the  cup-bearer  of  Henry  III  was  bom  at  five  months; 
Avicenna,  Diemerbroeck,  Vallesius,  and  Mena  speak  of  facts  nearly  similar,  and 
quite  as  authentic. 


228  THE  FOETUS. 

589.  While  admitting  with  Chaussier,  M.  Orfila,  and  some  others, 
that  none  of  the  facts  related  by  the  authors  demonstrate  beyond 
reply  that  the  foetus  is  viable  before  the  seventh  month,  I  cannot, 
however,  agree  with  them  that  the  thing  is  impossible.  A  woman 
came  in  1826  to  be  delivered  at  my  amphitheatre,  after  she  had  had 
a  fall ;  her  last  child  was  six  months  and  three  days  old ;  she  sup- 
posed herself  to  be  only  five  months  gone  with  child,  and  if  she  had 
had  commerce  with  her  husband  fifteen  or  even  twelve  days  after 
her  lying-in,  it  was  at  any  rate  impossible  for  her  to  have  entered 
on  her  seventh  month.  Now  this  woman  brought  into  the  world  a 
little  girl  that  weighed  two  pounds,  which  besides  presented  all  the 
appearances  of  a  foetus  of  about  five  months,  whose  cries  were  so 
weak  they  could  scarcely  be  heard,  who  notwithstanding  breathed, 
and  lived  in  this  state  for  four  days. 

690.  In  the  course  of  the  same  year,  a  young  woman  miscarried 
at  the  hospital  de  Perfectionnement ;  having  been  delivered  of  a  child 
at  term  five  months  and  twelve  days  before,  in  the  same  hospital,  it 
was  impossible  for  her  to  be  more  than  five  months  pregnant.  The 
fcetus  she  brought  forth  weighed  only  one  pound  and  a  quarter,  its 
skin  was  of  a  bright  rose  colour,  and  had  on  it  no  down  nor  seba- 
ceous matter ;  its  length  from  the  vertex  to  the  sole  of  the  foot  was 
only  nine  inches.  Notwithstanding  this,  my  attention  and  that  of  the 
pupils  was  attracted  to  it  by  some  stretchings  and  slight  movements 
of  its  limbs ;  we  wrapped  the  delicate  creature  in  cotton,  and  placed 
it  near  its  mother,  who  was  told  to  pour  a  few  drops  of  milk  into  its 
mouth  from  time  to  time ;  but  as  she  thought  such  an  abortion  could 
not  live,  she  did  not  judge  it  proper  tp  do  any  thing  to  prevent  it 
from  dying.  It  expired  in  fact  the  next  morning,  twenty-eight  hours 
after  it  was  born. 

591.  My  object  is  not  by  any  means  to  maintain  that  these  foetuses 
were  viable;  I  merely  wish  to  show  that  it  is  not  strictly  correct  to 
say  in  a  positive  manner,  that  a  child  born  previously  to  the  last 
three  months  of  pregnancy  must  be  reputed  not  viable. 

592.  A  fcetus  is  viable  when  sufticiently  developed  to  move  its 
limbs,  and  when  it  really  does  move  them  ;  when  it  cries  and  breathes 
freely  ;  when  its  head  is  covered  or  begins  to  be  covered  with  hair ; 
when  its  skin  is  no  longer  transparent,  is  covered  with  down  and 
coated  with  sebaceous  matter  ;  when  the  bones  of  the  cranium  touch 
along  the  greater  part  of  their  edges,  and  the  sutures  and  fontanels 
are  consequently  very  much  closed  ;  when  it  passes  oft"  its  meconium 
and  urine ;  wiicn  the  proportions  and  dimensions  of  the  different 
parts  of  its  body  arc  not  too  far  removed  from  what  is  observed  in 
foetuses  at  term  :  and  not  because  it  is  exactly  seven  months  old  or 


VIABILITY  OF  THE  F(ETUS. 

more.  For  the  same  reason  it  ought  not  to  be  declared  not  viable 
because  it  is  born  before  the  three  last  months  of  gestation,  but  rather 
because  the  absence  of  its  cry,  a  respiration  scarcely  discernible, 
very  feeble  motions,  inability  to  take  hold  of  the  nipple  or  finger,  to 
void  its  meconium  and  urine,  softness  and  separation  of  the  bones  of 
the  head,  the  absence  or  fewness  of  hairs,  the  transparency  and  red 
colour  of  its  skin,  the  want  of  a  sebaceous  deposit,  the  thinness  of 
its  nails,  &c.,  prove  that  its  organs  are  still  far  from  the  degree  of 
perfection  necessary  for  the  maintenance  of  its  exterior  life. 

693.  Hippocrates  and  many  other  physicians  of  antiquity  taught 
that  the  foetus  is  more  viable  at  seven  months  than  at  eight.  At  first 
view,  such  a  proposition  appears  somewhat  absurd  ;  all  other  things 
being  equal,  a  foetus  likely  to  live  at  the  seventh  month,  will,  a  for- 
tiori, be  viable  if  not  born  until  the  eighth  month.  The  very  strong 
movements  of  the  foetus  about  the  seventh  month,  and  which  gave 
rise  to  a  belief  in  the  somerset,  rendering  premature  delivery  much 
more  common  at  that  period  than  at  any  other,  the  ancients  drew 
from  it  the  conclusion  that  the  seventh  month  is  a  natural  term  of 
pregnancy,  and  that  if  the  foetus  over-passes  that,  it  could  not  be 
born  without  danger  until  the  end  of  the  ninth  month.  It  is  difficult 
to  understand  how  they  should  have  made  a  double  mistake  on  this 
subject,  unless,  with  M.  Dubois,  we  admit  as  a  fact,  that  if  labour 
takes  place  in  consequence  of  the  lively  agitation  of  the  foetus,  as 
pretty  often  happens  at  the  seventh  month,  the  cervix  dilating  with 
its  accustomed  gentleness  and  regularity,  the  child  will  be  exposed 
to  less  risk  than  if  born  at  eight  months,  when  delivery  is  provoked 
by  a  fall  or  some  other  external  accident.  In  the  former  case,  in 
fact,  early  parturition  is  in  some  sort  natural,  while  in  the  latter,  it 
is  only  a  kind  of  abortion. 


ARTICLE  III. 
Of  Mnormal  Expulsions  of  the  Human  Ovum. 

SECTION  1. 

Of  Abortion. 

594.  When  the  expulsion  of  the  ovum  takes  place  within  the  first 
six  months  of  pregnancy,  it  is  called  an  abortion,  miscarriage,  or 
blessure. 


230  THE  F(ETUS, 

According  to  Aristotle,  "if  the  foetus  comes  away  before  the 
seventh  day  after  the  conception,  the  accident  is  called  a  show  ;  at 
a  later  period,  but  before  the  fortieth  day,  the  woman  is  said  to  be 
wounded."  In  the  former  case  it  is  an  efflux;  according  to  Bonac- 
ciolus,  effluxiones,  qucs  intra  diem  septimum;  in  the  latter  it  is  an 
aborsus ;  ahorsus  qum  primis  mensis ;  or  an  abortus ;  abortus  qu<B 
intra  quadragesimum.  But  these  arbitrary  and  insignificant  dis- 
tinctions have  been  neglected  for  a  century  past,  both  by  physicians 
and  accoucheurs. 

595.  Frequency.  In  twenty-one  thousand  nine  hundred  and  sixty 
cases  of  pregnancy,  Madame  Lachapelle  informs  us  that  she  observed 
one  hundred  and  sixteen  abortions.  According  to  that  author,  mis- 
carriages are  more  frequent  at  six  months,  then  at  five,  then  at  three, 
than  at  any  other  period  of  gestation.  M.  Desormeaux,  in  accord- 
ance with  almost  all  the  ancient  authors,  with  reason,  and  with  my 
own  observations,  thinks,  on  the  contrary,  that  it  is  the  more  com- 
mon as  pregnancy  is  less  advanced.  If  Madame  Lachapelle  men- 
tions a  different  result,  it  is  evidently  because  abortion  in  the  early 
periods  does  not  occasion  so  much  inconvenience  to  women  as  to 
cause  them  to  go  to  the  hospital ;  which  is  not  the  case  after  the 
first  half  of  pregnancy  has  been  passed  through ;  or  perhaps  because 
in  the  first  six  weeks,  the  ovum  and  the  embryo,  frequently  confound- 
ed with  clots  of  blood,  occasion  the  woman  to  suppose  that  she  has 
only  had  a  return  of  the  menses,  while  at  a  later  period  she  cannot 
make  such  a  mistake. 

59G.  Morgagni  was  of  opinion  that  he  had  noticed  more  abortions 
of  female  than  of  male  foetuses;  M.  Desormeaux  is  of  the  same  way 
of  thinking,  and  says  that  if  the  vulgar  think  differently,  it  is  owing 
to  the  circumstance,  that  in  the  early  stages  it  is  very  easy  at  a  first 
glance  to  mistake  a  girl  for  a  boy.  This  remark,  which  had  been 
previously  made  by  Morgagni,  is  very  just,  provided  it  be  applied 
only  to  the  first  two  or  three  months.  Madame  Lachapelle  has  seen 
more  female  than  male  embryos,  and  more  male  than  female  foetuses. 
Upon  the  whole,  abortions  of  females  seem  to  exceed  those  of  males 
in  proportion  to  the  nearness  to  the  period  of  conception  ;  and  if  it 
were  true,  as  it  is  in  Germany  said  to  be,  that  the  two  sexes  are  at 
first  confounded,  or  that  the  creation  of  the  female  sex  depends 
merely  upon  an  arrest  of  the  growth  of  the  genital  organs,  the  female 
abortion  ought  to  be  the  only  one  at  the  early  stage. 

507.  Causes.  It  appears  that  the  causes  of  abortion  have  been 
till  lately  b\it  ill  understood,  and  the  labours  of  M.  Desormeaux,  of 
Madame  Lachapelle,  of  M,  Dugos  and  Madame  Boivin  could  not 
have  come  more  opportunely  to  throw  some  light  upon  this  matter. 


ABORTION.  231 

They  may  be  divided  into  remote  and  proximate  causes ;  or  into 
efficient  and  determining  causes.  The  proximate  or  efficient  causes 
are  constituted  by  the  contractions  of  the  womb,  assisted  by  the  mus- 
cular efforts  of  the  woman ;  the  determining  causes  may  be  divided 
into  predisposing  and  occasional. 

The  predisposing  causes  may  be  connected  with  the  state  of  the 
woman  or  of  the  ovum ;  relatively  to  the  woman,  some  of  them  de- 
pend on  certain  general  dispositions  of  the  economy,  and  others  on 
a  special  state  of  the  sexual  organs  only. 

598.  General  state.  Women  who  are  plethoric,  who  menstruate 
abundantly  and  regularly,  who  are  irritable,  excessively  sensitive, 
nervous,  hysterical,  lymphatic,  of  a  fair  complexion,  weakly,  sickly, 
who  have  large  eyes  and  a  bluish  sclerotica ;  persons  affected  with 
syphilis,  scurvy,  rickets  ;  those  who  have  a  badly  formed  pelvis,  some 
organic  lesion,  or  any  chronic  disease ;  those  who  are  asthmatic, 
dropsical,  affected  with  cancer ;  those  who  are  badly  nourished,  and 
those  who  compress  their  bellies  by  lacing,  or  wear  their  clothes  too 
tight,  miscarry  more  frequently  than  others  :  and  the  reason  of  it  may 
be  easily  conceived.  Marshy  and  unhealthy  countries ;  certain  atmos- 
spheric  constitutions,  formerly  mentioned  by  Hippocrates,  and  fre- 
quently observed  since  his  day,  and  which  render  abortions  really 
epidemic  at  some  seasons;  watchings,  and  fatiguing  occupations 
are  also  classed  among  the  predisposing  causes  of  miscarriages. 

599.  Affections  of  the  sexual  organs.  On  the  part  of  the  sexual 
organs  these  are,  all  the  chronic  diseases  to  which  they  are  subject, 
adhesions,  deformity,  displacements  ;  alterations,  whether  scirrhous, 
encephaloid,  or  hydatiform  ;  sub-inflammation  of  the  ovaries  and  all 
the  disorders  that  it  occasions  ;  organic  alterations  of  the  Fallopian 
tubes  ;  fibrous,  polypous  or  other  productions  in  the  tissue  of  the 
womb  itself,  or  the  neighbouring  parts  ;  preternatural  adhesions  of 
the  broad  or  round  ligaments,  or  of  the  tubes  or  ovaries  to  the  sur- 
rounding parts,  or  to  each  other  ;  chronic  metritis  and  all  its  con- 
sequences ;  anteversion  and  retroversion ;  scirrhus  and  cancer ; 
transformations  and  affections  of  whatsoever  nature  ;  in  fine,  what- 
ever may  interfere  with  the  easy  and  regular  enlargement  of  the 
womb  during  pregnancy. 

600.  This  genus  of  causes,  formerly  noticed  by  several  authors, 
amongst  others  by  M.  Delpech,  has  lately  been  well  discussed  by 
Madame  Boivin  in  a  memoir  ad  hoc,  which  in  fact  deserves  the  at- 
tention of  every  accoucheur  ;  its  mechanism  and  frequency  may  be 
easily  conceived  of  by  reflecting  on  the  aflections  that  take  place 
in  a  multitude  of  women  at  the  period  of  puberty,  before  or  after 
the  occiirrence  of  tliat  revolution,  and  indeed  at  all  periods  of  their 


232  THE  FCETUS. 

lives ;  affections  that  are  most  generally  occasioned  by  a  material 
lesion  of  some  portion  of  the  generative  system  ;  and  do  not  com- 
monly disappear  without  leaving  behind  them  the  indelible  traces  of 
their  existence.  Sometimes  it  is  a  tumour  in  the  excavation  that 
prevents  the  enlargement  of  the  uterus  ;  at  others  it  is  an  ovary  that 
has  degenerated  or  been  transformed  into  a  cyst,  and  become  lodged 
in  the  recto-vaginal  fossa,  a  case  of  which  came  under  my  own  no- 
tice ;  sometimes  the  right  tube  is  glued  to  the  ligament  of  the  left 
ovary,  and  vice  versa,  and  even,  besides,  so  as  to  adhere  behind  the 
cervix,  of  which  I  saw  an  instance  in  a  woman  who  died  when  about 
three  months  gone  with  child ;  more  frequently,  there  are  encepha- 
loid  and  scirrhous  masses,  either  occasioned  by  the  pregnancy,  or 
whose  germs  existed  previously  to  the  conception,  which,  by  affecting 
the  ovaries,  the  tubes,  the  pelvic  peritoneum,  or  the  substance  itself  of 
the  womb,  oppose  an  invincible  obstacle  to  the  changes  of  structure 
and  dimensions  indispensable  in  these  organs  for  the  completion  of 
gestation,  of  which  I  have  collected  pretty  numerous  examples,  &c. 

601.  Leucorrhoea,  hydrometry,  irritability  ;  too  great  a  degree  of 
contractility  ;  rigidity  of  the  fibres  and  even  of  the  vessels,  and  if  we 
may  believe  Hauenschild  and  Loder,  of  the  peritoneum  of  the  uterus ; 
and  a  laxity  or  atony  of  its  neck,  on  which  M.  Desormeaux  rationally 
insists,  are  also  admitted  among  the  number  of  the  predisposing 
causes  of  abortion  ;  but  for  the  most  part  their  action  is  far  from 
being  so  evident  as  the  preceding.  The  same  may  be  said  of  a  want 
of  extensibihty  of  the  uterus,  occasioned  by  a  too  great  firmness  of 
its  fibres,  a  firmness  on  which  many  authors  lay  so  much  stress. 
According  to  their  statements,  abortion  is  to  be  feared  because  the 
womb  does  not  yield  with  facility  to  the  effort  which  tends  to  dis- 
tend it.  In  this  respect,  their  language,  always  similar  to  that  of 
the  ancients,  who  supposed  that  the  ovum  acted  mechanically  upon 
the  womb,  would  load  us  to  suppose  that  there  is  a  sort  of  contest 
between  the  containing  and  the  contained  ;  however,  nothing  of  the 
sort  takes  place  :  the  womb  enlarges  in  consequence  of  the  unfolding 
of  its  fibres,  and  the  affluxion  of  fluids  into  its  vessels ;  the  ovum 
ceases  to  grow  us  soon  as  the  organ  that  contains  it  ceases  to  de- 
velopc  itself,  and  abortion  may  follow  as  a  consequence  thereof,  but 
without  our  being  able  to  accuse  a  distending  power  which  it  by 
no  means  possesses.  By  rigidity  of  the  uterus  wc  ought  to  under- 
stand a  want  of  disposition  in  it  to  imbibe,  to  soften  and  distend,  in 
consequence  of  the  accumulation  of  fluids  in  the  interstices  of  its 
tissue,  and  not  any  resistance  it  may  oppose  to  the  sweUing  of  the 
ovum. 

602.  Diseases  of  the  ovum.     The  foundation  of  an  abortion  in  a 


ABORTION.  233 

majority  of  cases  is  laid  in  some  peculiar  disposition  of  the  ovum 
itself,  and  I  am  astonished  that  authors  have  paid  so  little  attention 
to  this  predisposing  cause :  like  fruits  that  perish  before  they  have 
attained  their  full  growth,  and  separate  and  fall  at  the  slightest  shake 
of  the  branch  on  which  they  grow,  so  the  embryo  or  the  foetus  in  ani- 
mals must  become  detached  and  soon  afterwards  expelled  from  the 
womb  when  it  has  ceased  to  live. 

603.  The  alterations  capable  of  bringing  about  the  death  of  the 
ftetus  are  extremely  numerous,  and  so  much  the  more  so,  in  pro- 
portion as  the  pregnancy  is  advanced.  Since  I  began  to  pay  regu- 
lar attention  to  flie  subject  of  embryology,  I  have  carefully  observed 
one  hundred  and  fifty  products  that  had  not  gone  beyond  the  term 
of  three  months ;  now  I  can  assert  that  of  this  number  at  least  one 
half  were  diseased. 

604.  Sometimes  the  disease  commences  in  the  membranes ;  the 
chorion  thickens,  becomes  opaque,  and  is  covered  with  rugosities 
on  its  internal  surface;  the  granulations  on  its  external  surface 
swell,  and  give  birth  to  hydatids-in^bunches  in  the  womb,  and  to 
the  hydatiform  mole,  which  Madame  Boivin  erroneously  regards  as 
a  dependency  on  the  amnios,  &c. ;  the  latter  undergoes  alterations 
that  are  nearly  similar,  is  disorganized,  or  contracts  adhesions  with 
the  surrounding  parts ;  the  placenta  is  not  formed,  or  is  irregularly 
developed,  is  transformed  into  hydatic  granulations,  and  becomes  the 
seat  of  all  sorts  of  degenerations. 

Sometimes,  and  perhaps  most  frequently,  the  disease  attacks  the 
umbilical  vesicle  or  its  duct ;  in  others  it  affects  the  cord  or  the  em- 
bryo itself,  and  in  this  respect  the  forms  and  degrees  of  the  altera- 
tions are  exceedingly  various. 

605.  Almost  all  the  diseases  to  which  the  child  is  liable  after 
birth,  may  manifest  themselves  during  its  intra-uterine  life.  In  an 
embryo  of  two  months  1  have  seen  adhesion  of  the  whole  length  of 
the  members  to  the  trunk ;  I  have  seen  ulcerous  destruction  of  the 
head,  belly,  hand,  &-c.  in  subjects  quite  as  young  as  the  above- 
mentioned  ;  also,  manifest  alterations  in  the  lungs,  the  liver,  the  peri- 
toneum, and  other  parts  of  the  body  as  early  as  the  third  month  ;  I 
have  found  the  umbilical  cord  in  a  state  of  atrophy,  and  its  vessels 
either  quite  or  almost  obliterated,  at  every  stage  of  its  development. 
In  several  specimens  the  umbilical  vesicle  was  hard,  and  as  it  were, 
stony  ;  in  others  it  was  full  of  a  clear  limpid  fluid,  and  in  two  cases 
it  was  not  of  a  natural  size,  nor  had  it  the  other  appearances  that 
naturally  belong  to  it.  In  some  embryos  the  head  alone  was  atro- 
phied and  deformed  ;  in  others  the  same  state  w&a  observed  in  one 
or  more  of  the  limbs,  the  breast  or  the  belly  j  most  commonly,  the 

2E 


234 


THE  F(ETUS. 


atrophy,  or  the  disorganization  is  general,  and  in  some  cases  the 
embryo  at  last  wholly  disappears.  In  such  instances  the  annnios  is 
most  commonly  destroyed  also  ;  I  have  many  times  found  the  ovum  a 
mere  sac,  filled  with  an  albuminous,  limpid  and  viscid  fluid  ;  I  could 
almost  believe  with  Walter,  Burns,  Beclard,  and  M.  Duges  that 
such  ova,  composed  merely  of  the  caduca  and  chorion,  had  never 
contained  an  embryo ;  that  they  might  be  compared  to  those  eggs 
without  germs,  that  are  laid  by  pullets,  that  have  never  been  fecun- 
dated by  the  cock ;  but  as  in  several  of  them  there  were  still  to  be 
found  the  traces  of  an  amnios,  an  umbilical  cord,  or  of  the  foetus 
itself,  it  was  necessary  to  renounce  such  an  idea  at  once. 

606.  I  have,  besides,  certain  proof  that  most  of  the  cases  of  mon- 
strosity, even  those  whioh  in  our  times  are  so  complacently  ac- 
counted for  on  the  theory  of  an  arrest  in  the  process  of  evolution, 
are  nothing  more  than  the  results  of  disease  in  some  part  of  the 
ovum  ;  but  I  reserve  the  development  of  these  assertions  for  another 
work  ;  let  it  suffice  to  remark  in  this  place,  that  the  human  embryo, 
a  mere  vegetable  during  the  first  months  of  pregnancy,  is  surrounded 
with  too  many  causes  of  destruction  to  be  able  always  to  resist  them 
successfully  ;  that  nothing  ought  to  be  more  easy  to  ascertain  than 
the  disease  and  even  the  death  of  a  being  whose  existence  is  so  frail 
and  precarious ;  and  finally,  whenever  the  ovum  is  diseased  to  such 
an  extent  as  to  cause  the  death  of  the  embryo,  abortion  is  in  some 
measure  one  of  its  necessary  consequences. 

607.  I  will  not,  with  Madame  Lachapelle,  say  that,  after  the  death 
of  the  fcEtus,  the  womb  becomes  the  seat  of  a  congestion,  because 
the  blood,  which  previously  passed  into  the  placenta,  surcharges  it 
by  stagnating  in  its  vessels  ;  nor  that  this  embarrassment,  definitively, 
is  the  cause  of  abortion.  Such  a  supposition  does  not  appear  to  me 
to  be  tenable,  and  I  should  not  have  alluded  to  it,  had  not  M.  De- 
sormeaux  seemed  to  lend  it  a  new  force  by  the  strength  of  his  au- 
thority. As  soon  as  the  ovum  ceases  to  live,  it  becomes  only  a 
foreign  body  in  the  uterus ;  thenceforth  the  organism  tends  to 
throw  it  off,  as  it  does  whatever  interferes  with  its  operations,  as  a 
thorn,  for  example,  but  not  because  the  blood  primarily  destined 
for  the  foetus  is  compelled  to  re-enter  the  torrent  of  the  niatornal 
circulation. 

608.  Weakness  of  the  foetus,  its  convulsive  motions,  tlie  super- 
abundance, or  too  small  quantity  of  the  liquor  amnii,  circumvolu- 
tions of  the  cord  around  its  neck,  dtc,  knots  in  it,  its  shortness,  its 
excessive  length,  cysts,  or  any  accumulations  of  fluids  between  the 
membranes,  eflusions  of  various  kinds,  whether  difluse  or  circum- 
icribed,  in  the  substance  of  the  placenta  or  caduca,  are  also  causes 


ABORTION.  235 

capable  of  bringing  on  abortion,  but  not  inevitably,  like  the  affec- 
tions I  spoke  of  just  now. 

609.  Occasional  causes.  The  predisposing  causes  alone  would 
very  rarely  fail  to  bring  on  the  expulsion  of  the  ovum ;  they  in  fact 
frequently  do  produce  it,  and  in  these  cases  the  abortion  is  said  to 
be  spontaneous;  however,  it  is  almost  always  attributed  to  some 
accident,  some  particular  circumstance,  which,  in  the  eyes  of  the 
public,  and  even  of  many  physicians,  passes  as  the  only  and  principal 
cause  of  it.  The  generality  of  people  being  unable  to  conceive,  and 
professional  people  having  scarcely  imagined  that  the  principle  of 
abortion  might  reside  in  the  ovum  itself,  it  has  followed  that  a  thou- 
sand insignificant  causes  have  by  turns  been  brought  to  its  explana- 
tion ;  that  the  slightest  actions,  those  capable  of  effecting  the  smallest 
change  in  the  economy,  have  been  classed  amongst  its  occasional 
causes. 

610.  Such  for  example  among  others  are  yawning,  pandiculation, 
the  act  of  going  to  stool,  of  voiding  urine,  of  coughing,  great  exer- 
tions, disappointments,  joy  or  grief,  the  odour  of  the  snuff  of  a  can- 
dle, the  impression  of  any  strong  odour  whatever,  an  hysterical  fit, 
epilepsy,  coitus,  dancing,  sleeplessness,  diarrhoea,  tenesmus,  and  all 
the  causes  that  might  occasion  uterine  hemorrhage  during  preg- 
nancy. 

611.  I  do  not  wish  to  be  understood,  however,  that  none  of  these 
causes  may  give  rise  to  abortion ;  but  only,  that,  without  the  ante- 
cedent existence  of  one  of  the  predisposing  causes  above  enume- 
rated, they  would  scarcely  ever  determine  it,  and  that  they  most 
commonly  are  merely  coincidences.  The  same  may  be  said  of  the 
acute  diseases  of  the  woman,  of  asphyxia,  of  all  sorts  of  inflamma- 
tions, of  crying,  of  singing,  of  the  jolting  of  a  carriage,  of  vomiting, 
of  the  use  of  certain  medicines,  of  falls,  blows,  violent  motion  of 
what  part  of  the  body  soever,  of  any  thing  that  might  shake  or  shock 
the  uterus. 

612.  It  has  been  generally  thought  that  these  causes  act  by  de- 
taching the  placenta;  but  when  it  is  remembered  that  the  ovum  fills 
the  womb  exactly,  and  is  itself  perfectly  filled  with  the  liquor  amnii 
and  foetus,  it  is  evident  that  motions  impressed  on  the  womb  by  ex- 
ternal shocks  are  as  incapable  of  separating  the  placenta  from  the 
womb,  or  the  chorion  from  the  amnios,  as  they  would  be  to  separate 
two  bladders,  one  contained  within  the  other,  and  the  inner  one  full 
of  fluid  :  the  most  active  and  imprudent  women,  those  who  give 
themselves  up  to  the  most  violent  exercises,  do  not  on  that  account 
fail,  most  generally,  to  go  their  full  time ;  while  many  others  are 
found  to  abort  in  spite  of  the  most  minute  precautions,  and  the  most 


236  THE  FCETUS. 

persevering  attentions.  A  woman,  says  Mauriceau,  who  was  seven 
months  gone  with  child,  in  order  to  escape  from  her  chamber,  which 
was  on  fire,  got  out  of  a  third  story  window  ;  fear  soon  made 
her  let  go  her  hold,  and  she  fell  on  the  stoftes,  and  fractured  her 
fore-arm,  but  her  pregnancy  was  not  disturbed.  A  young  midwife, 
mentioned  by  Madame  Lachapelle,  who  was  pregnant,  and  affected 
with  deformed  pelvis,  threw  herself  from  the  top  of  a  stair  into  a 
deep  cellar,  with  a  view  to  bring  on  abortion,  and  thereby  avoid  the 
Cesarean  operation  :  she  died  a  few  days  afterwards  of  her  wounds, 
but  there  was  no  abortion. 

613.  Medication.  Bloodletting,  baths,  emetics,  purgatives  and 
emmenagogues  also  enjoy  a  great  reputation  among  the  women,  as 
abortives,  which  happily  is  but  little  deserved.  Diseases  are  daily 
met  with  in  practice  which  require  repeated  bleedings,  whether  ge- 
neral or  local,  and  for  which  the  tartar  emetic  is  administered,  as  well 
as  drastic  purgatives  and  other  equally  active  substances,  without  the 
pregnancy  seeming  to  suffer  from  them.  Mauriceau  speaks  of  a 
woman  who  was  bled  from  the  arm  eighty-six  times  in  one  preg- 
nancy, and  who  notwithstanding  was  at  the  end  of  it  delivered  of  a 
fine  large  child  :  he  mentions  another  who  was  bled  from  the  foot 
ten  times  without  experiencing  any  inconvenience.  Delamotte  has 
seen  the  most  powerful  evacuants  produce  gastritis,  enteritis,  perito* 
nitis  and  even  death  itself,  without  being  followed  by  the  expulsion 
of  the  ovum.  I  had  the  care  of  a  young  person  who,  with  a  design 
of  concealing  the  proofs  of  her  dishonour,  had  produced  a  violent 
abdominal  inflammation  by  taking  medicines  to  promote  abortion  ' 
she  died  on  the  eighth  day  without  any  symptom  of  abortion  havintr 
appeared.  I  was  consulted  for  another  person,  who  had,  with  the 
same  view,  taken  fifteen  grains  of  tartarized  antimony  :  it  produced 
most  violent  efforts  at  vomiting,  but  the  progress  of  the  pregnancy 
was  not  interrupted. 

614.  It  ought  not  however  to  be  concluded  from  the  above  facts  that 
bloodletting,  particularly  from  the  foot,  or  the  application  of  leeches 
to  the  vulva,  or  that  baths  too  frequently  repeated,  &c.  can  never 
be  injurious  to  pregnant  women  ;  I  merely  wish  to  say,  that  except 
in  case  of  some  peculiar  predisposition,  these  measures  most  com- 
monly produce  no  effect,  and  that  they  may  be  had  recourse  to  if 
circumstances  require  them,  just  as  if  the  woman  were  not  pregnant. 

615.  M.  Dcsormeaux  had  already  pointed  out  the  fact  that  abor- 
tion is  frequently  preceded  by  a  state  of  irritative  congestion  of  the 
uterus,  a  general  febrile  excitement,  (he  train  of  symptoms  which 
constitute  tjio  molimen  liemorrhagicum.  Very  recently  Madame  La- 
chapelle and  M.  Duges  have  strongly  insisted  on  this  condition,  to^ 


ABORTION.  237 

wards  which,  in  fact,  almost  all  the  predisposing  and  occasional 
causes  of  abortion  tend,  previously  to  bringing  into  play  the  con- 
tractile powers  of  the  womb  ;  but  it  was  an  error  to  regard  it  as  the 
primitive  cause  of  almost  all  miscarriages ;  it  is  commonly  only  a 
secondary  phenomenon,  an  effect  of  some  other  external  or  internal 
cause,  and  not  a  necessary  result  of  any  of  them  ;  however,  there  are 
j^Bome  women  who  exhibit  it  in  an  evident  manner  at  each  menstrual 
j|pperiod  throughout  the  whole  course  of  gestation  ;  whence  it  follows, 
^that  it  may  suffice  to  detach  the  ovum,  especially  within  the  first 
three  or  four  months,  and  that  Klein,  as  approved  by  M.  Desor- 
meaux,  Madame  Lachapelle  and  M.  Duges,  had  a  right  to  say,  that 
abortion  is  never  more  common  than  during  the  menstrual  periods  ; 
besides,  it  plays  in  this  case  the  same  part  it  does  in  the  causation 
of  floodings. 

616.  Periodical  abortion,  or  that  which  in  the  same  woman  re- 
curs at  nearly  the  same  period  from  conception,  is  one  which  ap- 
pears to  be  most  evidently  connected  with  a  menstrual  or  spontaneous 
molimen.  It  may,  however,  also  depend  on  a  special  state  of  the 
womb,  either  congenital  or  acquired  ;  for  example,  upon  the  womb 
being  incapable  of  distension  beyond  a  certain  degree.  On  this 
point  the  influence  of  habit  or  hereditary  constitution  is  commonly 
referred  to ;  the  cases  of  many  women  are  cited  whose  mothers 
were  subject  to  abortion,  and  never  able  to  carry  a  foetus  to  full 
terra.  Observation  has  proved  that  miscarriage  is  so  much  the 
more  to  be  apprehended  in  proportion  as  the  individual  has  been 
previously  subject  to  it ;  the  case  is  mentioned  of  a  young  girl  who, 
having  by  criminal  methods  several  times  procured  abortion  of  her 
fcEtuses,  could  never  carry  one  to  the  full  term  after  she  became  a 
married  woman. 

617.  The  mechanical  causes,  or  certain  manmuvres^  recommended 
by  some  authors,  in  cases  of  deformity  of  the  pelvis,  and  which  in 
the  midst  of  our  refined  society  are  also  employed  by  degraded 
wretches  not  less  criminal  than  the  unnatural  women  who  are  not 
ashamed  to  submit  to  their  disgusting  ministrations,  must  be  arranged 
amongst  the  same  class  with  emmenagogues  and  drastic  purgatives. 
Those  who  make  use  of  them  most  frequently  fail  of  attaining  their 
object,  and  succeed  only  in  seriously  injuring  the  womb.  I  once 
prescribed  for  a  female,  in  whom  such  attempts  had  brought  on  a 
flooding  which  conducted  her  to  the  verge  of  the  grave ;  she  suffered 
horribly  from  pain  in  the  interior  of  the  pelvis  for  two  months,  not- 
withstanding which  abortion  did  not  take  place,  and  she  is  now 
a  prey  to  a  large  ulcer  of  the  neck  of  the  womb.  I  opened  tiie 
body  of  an  unhappy  creature  who  sufiered  from  the  like  attempts. 


238  THE  FCETUS, 

which  did  not  succeed  any  better  than  the  one  above  mentioned. 
M.  Girard  of  Lyons  mentions  a  similar  instance.  Very  recently, 
also,  (October  1828)  a  young  woman,  who  became  pregnant  against 
her  wishes,  succeeded  by  such  manosuvres  only  in  producing  an 
organic  lesion  of  the  uterus,  which,  after  frightful  sufferings,  led  her 
to  the  commission  of  suicide. 

618.  Signs.  After  protracted  disease,  and  within  the  first  two  or 
three  months,  tlie  expulsion  of  the  ovum  is  often  effected  without 
being  accompanied  by  any  particular  symptoms,  and  does  not  sen- 
sibly differ  from  what  takes  place  at  a  somewhat  painful  menstrual 
period.  But  at  a  more  advanced  stage  it  can  only  give  rise  to  the 
ordinary  phenomena  of  a  natural  labour ;  yet  it  is  most  commonly 
preceded  by  lowness  of  spirits,  a  general  depression,  by  lipothymia, 
syncope,  a  feeling  of  coldness  in  the  epigastrium,  palpitations,  pale- 
ness, fetid  breath,  flaccidity  of  the  breasts,  and  a  major  part  of  the 
rational  signs  indicative  of  the  death  of  the  foetus.  Ordinarily,  as 
has  been  before  remarked  by  Roderic  a  Castro,  MM.  Foder6  and 
Desormeaux,  Madame  Lachapelle  and  M.  Duges,  the  woman  at 
first,  for  one  or  more  days,  has  rigors,  horripilation,  a  hot  skin, 
thirst,  want  of  appetite,  increased  movements  of  the  heart  and  arte- 
ries, a  feeling  of  weight  in  the  pelvis,  about  the  fundament  or  loins, 
and  a  general  lassitude  of  the  limbs,  as  if  threatened  with  some 
severe  disease ;  next  appears  hemorrhagy,  accompanied  with  pain 
of  greater  or  less  severity,  and  all  the  symptoms  of  real  labour;  but, 
amongst  all  these  signs,  scarcely  any,  saving  hemorrhage  and  pain, 
afford  any  certainty  previously  to  the  dilatation  of  the  cervix,  and 
the  presence  of  a  portion  of  the  ovum  in  the  upper  part  of  the 
vagina. 

619.  Hemorrhage  itself  is  not  invariably  followed  by  abortion,  as 
is  proved  by  the  observations  of  Mauriceau,  Raymond,  de  Boer, 
&c.;  nevertheless,  there  is  good  reason  to  fear  it  when  that  symptom 
once  takes  place.  But  before  we  accord  to  it  any  value,  we  should 
know  how  to  distinguish  it  from  the  menstrual  discharge,  which 
sometimes  continues  throughout  the  whole  of  pregnancy.  I  have 
already  at  another  place  (312)  hinted  that  this  discrimination  is 
at  the  beginning  very  difficult,  and  must  here  repeat  that  this  kind 
of  abnormal  menstruation,  to  which  Madame  Lachapelle  appears 
not  to  give  much  faith,  is  notwithstanding  not  of  very  rare  occur- 
rence ;  I  could  add  two  instances  to  those  related  by  Portal,  De- 
venlcr,  Amand,  Baudelocque,  &c.,  and  I  can  affirm  that  in  these 
two  women  the  catamenia;  had  never  occurred  with  greater  regu- 
larity. 

620.  Aa  to  the  pains^,  it  is  importaDt  that  they  should  not  be  coi>- 


ABORTION.  339 

fouDcled  with  the  colic,  or  with  those  uterine  pains  that  are  also 
occasionally  met  with  during  menstruation  ;  for  this  end,  reference 
should  be  made  to  the  signs  indicated  in  regard  to  the  pains  of 
labour. 

621.  The  discharge  of  a  certain  quantity  of  brownish  matter,  or 
of  serosity,  the  softening  of  the  cervix,  the  rupture  of  the  mem- 
branes, the  formation  of  the  hag  of  waters  with  pains  extending 
from  the  navel  towards  the  excavation,  constitute  the  most  conclusive 
signs  of  miscarriage ;  nevertheless,  M.  Desormeaux  has  known  all 
these  signs  to  be  present  after  a  fall,  and  yet  abortion  did  not  ensue. 
M.  Morlanno  relates  the  case  of  a  woman  who  was  not  delivered 
until  six  weeks  after  the  discharge  of  the  waters ;  there  has  also 
been  recently  mentioned  the  case  of  a  woman  six  months  gone,  in 

t  which  the  bag  of  waters  was  formed,  and  then  ruptured,  so  that  the 
arm  of  the  child  engaged  in  the  vagina ;  after  which  the  labour  was 
^  arrested,  the  foetus  returned  to  its  proper  position,  and  the  preg- 
nancy proceeded  in  its  natural  course !  The  author  of  it  saw  and 
felt :  we  must  believe  him. 

622.  The  Jluid  that  escapes  from  the  cervix  may  besides  come 
from  an  hydatic  cyst,  or  from  between  the  membranes ;  in  such  a 
case,  it  is  very  evident  that  the  pregnancy  might  not  be  necessarily 
disturbed ;  it  may  also  proceed,  in  double  pregnancy,  from  the  rup- 
ture of  one  ovum,  while  the  other  may  not  suffer  the  least  alteration ; 
but  with  the  exception  of  these  anomalies,  it  appears  evident  that 
the  rupture  of  the  membranes,  followed  by  the  discharge  of  the 
waters,  positively  indicates  miscarriage,  or  at  least  the  death  of  the 
foetus,  if  it  is  not  soon  expelled. 

623.  The  child  having  ceased  to  live,  is  generally  soon  thrown 
out  by  the  uterus  ;  but  in  some  cases,  its  expulsion  does  not  take 
place  for  a  pretty  considerable  period.  I  have  seen  it  not  take  place 
until  the  twenty-eighth  day  in  a  woman  who  was  seven  months  with 
child.  In  another  woman,  the  pregnancy,  which  was  ascertained  by 
ballottement,  and  active  motion  of  the  fcEtus,  suddenly  stopped  at  six 
months  ;  all  the  signs  of  the  death  of  the  child  supervened ;  the  belly 
gradually  lost  one  half  of  its  size ;  from  this  period  eight  months 
elapsed  ;  the  cervix  remains  closed,  and  nothing  indicates  that  mis- 
carriage is  about  to  take  place  soon.  M.  Prout  gave  me  an  oppor- 
tunity of  seeing  a  foetus  of  from  three  to  four  months,  which  was  not 
discharged  for  five  months  after  the  first  symptoms  of  abortion,  and 
numerous  authors  have  mentioned  similar  instances. 

If  the  membranes  are  not  broken,  and  the  air  does  not  get  access 
to  their  interior,  the  foetus  may  be  preserved  without  ciiange  for 


240  THE  PcETUS. 

several  monthg,  or  even  several  years,  which  lias  given  rise,  I  ptd- 
sume,  to  the  supposed  pregnancies  of  fifteen,  twenty,  or  thirty  months 
duration,  &c.  that  are  spoken  of  in  the  scientific  collections.  This 
occurrence  is  met  with,  particularly  in  compound  pregnancy  :  one 
of  the  foetuses  dies  at  two  or  three  months ;  the  other  continues  to 
grow  ;  and  at  the  lying-in,  the  practitioner  is  astonished  to  receive 
both  a  full  grown  child  and  an  abortion.  I  am  in  possession  of  a 
great  number  of  facts  of  this  sort ;  MM.  Bouvier,  Colombe  and 
Defermont,  have  each  communicated  one  to  me,  and  many  of  the 
instances  of  superfcetation  that  have  been  most  insisted  on,  are  noth- 
ing more  than  such  as  these. 

At  other  times  it  is  decomposed,  putrefies,  passes  into  the  state 
of  adipocire,  and  then  the  pregnancy  goes  ou  as  indicated  when 
we  were  upon  the  subject  of  extra-utenne  pregnancy  (363).  In 
the  first  months  it  may  become  atrophied,  and  when  the  ovum  is 
thrown  oif,  only  exhibit  the  dimensions  of  an  embryo  of  four  or  five 
weeks,  although  the  woman  was  three  or  four  months  gone.  It 
may  also  dissolve  in  the  waters,  and  then  the  ovum  is  found  to  be 
transformed  into  a  real  mole.  If  the  membranes  give  way,  the 
fcBtus  generally  escapes  first,  and  the  membranes  follow  soon  after- 
wards. M.  Trelat,  however,  has  seen  a  case  in  which  the  ovum 
was  not  discharged  until  twelve  days  after  the  expulsion  of  its  in- 
volucra. 

624.  Although  the  foetus  may  no  longer  be  in  the  womb,  its 
coverings  may  still  stick  there  by  means  of  some  adhesion,  and  con- 
tinue to  live  and  grow.  The  caducous  membrane  soon  acquires 
a  considerable  degree  of  thickness ;  the  amnios  disappears ;  the 
cavity  of  the  chorion  by  degrees  contracts,  and  the  mass  comes  at 
last  to  be  a  reddish  fleshy  tumour,  in  the  centre  of  which  is  most 
commonly,  but  not  always,  found  a  small  serous  cavity.  In  this  way 
are  formed  most  of  the  jkshy  moles,  or  moles  of  generation.  The 
placenta  may  continue  to  grow  alone,  or  it  becomes  infiltrated,  and 
when  at  last  it  is  expelled,  it  exhibits  no  resemblance  to  its  original 
form  or  nature. 

626.  Sometimes  the  ovum  comes  away  whole ;  indeed,  this  is 
most  frequently  the  case  until  the  end  of  the  second  month ;  but 
after  this  its  size  does  not  admit  of  its  being  so  expelled,  in  a 
majority  of  instances,  and  so  much  the  less,  as  the  gestation 
is  at  a  more  advanced  stage ;  however,  I  saw  an  ovum  of  full  six 
months  expelled  at  the  Hospital  de  Perfectionnement,  which  was 
not  in  the  least  broken.  M.  Larrey  sent  me  another  of  five  months 
and  a  half,  which  was  also  quite  whole.     In  the  first  months  of 


ABORTION.  241 

pregnancy,  instead  of  coming  away  with  all  its  appendages,  the 
foetus  is  sometimes  expelled  with  the  amnios  alone,  or  with  its  am- 
nios and  chorion  only. 

626.  Prognosis.  A  miscarriage  is  generally  more  dangerous 
than  a  labour  at  term,  and  those  authors  have  erred  who  find  fault 
with  Hippocrates  for  having  uttered  this  opinion  ;  the  former  is  a 
disease,  while  the  latter  is  only  the  termination  of  a  natural  function. 
But  to  speak  correctly,  abortion  is  sometimes  not  such  a  serious 
matter  in  itself  considered,  but  because  the  causes  which  induce  it, 
and  the  accidents  which  accompany  it  generally  constitute  important 
diseases ;  because  the  pregnancy,  which  is  terminated  by  it,  has  re- 
called to  the  genital  organs  the  germ  of  affections  whose  existence 
was  not  suspected,  or  which  perhaps  would  have  never  reappeared 
but  for  it.  The  prognosis  ought  therefore  to  vary  according  to  cir- 
cumstances. If  ifappears  to  draw  in  its  train  a  variety  of  nervous 
aifections,  pains  in  the  hypogastrium,  chronic  inflammation  of  the 
womb,  ulcers,  degenerations,  and  all  sorts  of  organic  lesions,  it 
frequently  is  so  because  these  alterations  existed  previously  to  the 
miscarriage  itself;  excepting  always  those  cases  of  abortion  produced 
by  the  direct  agency  of  mechanical  causes. 

627.  The  least  dangerous  abortion  is  that  which  is  determined  by 
a  disease  of  the  ovum,  and  the  most  serious  is  that  which  a  violent 
occasional  cause,  unaided  by  any  predisposing  one,  has  given  birth 
to  ;  moreover,  all  other  things  being  equal,  a  spontaneous  abortion 
is  less  to  be  dreaded  than  a  forced  one,  and  in  general,  so  much  the 
less,  in  proportion  as  it  is  effected  with  gentleness  ;  the  danger,  which 
for  the  woman  is  greater  in  proportion  to  the  degree  of  advance- 
ment of  the  pregnancy,  is,  for  the  foetus,  the  same  at  all  stages  of  the 
gestation. 

Where  the  cervix  is  naturally  soft  and  relaxed,  while  the  rest  of 
the  womb  retains  its  ordinary  density,  the  miscarriage  is  both  easier 
and  less  serious  to  the  woman  than  in  the  contrary  circumstances  ; 
when  produced  by  a  very  decided  molimen,  if  there  are  no  compli- 
cations, it  may  terminate  as  favourably  as  the  most  simple  case  of 
parturition  ;  but  as  this  hemorrhagic  effort  is,  most  frequently,  merely 
the  first  degree  or  the  symptom  of  a  more  or  less  extensive  inflam- 
mation, there  is  reason  to  fear,  especially  if  fever' attends  it,  either  a 
metritis,  an  acute  peritonitis,  or  some  other  phlegmasia  equally 
dangerous.  Some  authors  have  contended  that  abortion  may  have 
its  advantages,  as  for  example,  to  render  menstruation  regular, 
or  restore  fecundity ;  but  it  is  evident  from  her  miscarrying,  that 
the  woman  was  not  sterile  ;  and  besides,  if  the  menses  sometimes 
2F 


242  THE  FCETUS. 

resume  their  original  type  after  an  abortion,  they  would  have  done 
so  with  more  certainty  after  a  complete  pregnancy. 

628.  I  can  conceive  of  only  one  case  in  which  abortion  could  be 
of  advantage  by  being  frequently  repeated,  and  that  is  where  the 
womb  is  not  sufficiently  permeable,  or  too  dense  to  dilate  in  pro- 
portion to  the  wants  of  the  ovum  ;  then  one  miscarriage  must  ne- 
cessarily diminish  this  abnormal  rigidity  a  little  ;  a  second  one  dimi- 
nishes it  still  more  ;  and  finally,  a  third  or  a  fourth  may  completely 
overcome  it  so  as  at  last  to  render  it  possible  for  the  woman  to  con- 
duct the  foetus  to  delivery  at  full  term. 

Treatment.  The  practitioner  should  turn  his  attention  to  the  pre- 
vention of  miscarriage,  for  when  it  has  once  commenced,  all  he  has 
to  do  is  to  hasten  its  termination. 

629.  The  preservative  treatment  must  necessarily  vary  according 
to  the  nature  of  the  determining  causes  we  have  to  remove  or  com- 
bat :  if  the  woman  is  irritable  and  very  sensible,  we  must  do  all  in 
our  power  to  protect  her  from  moral  commotions  ;  she  should  be 
kept  out  of  large  cities  ;  travelling  should  be  recommended  to  her 
for  change  of  scene,  &c.  Those  who  are  weakly  and  lymphatic, 
should  follow  an  analeptic  regimen,  and  keep  quiet,  or  at  least  en- 
gage only  in  agreeable  exercise  :  in  some  cases  a  tonic  medicine  may 
be  administered.  Should  there  be  a  disease  of  the  uterus  or  of 
some  other  organ,  its  nature  should  be  carefully  inquired  into,  so 
as  to  apply  the  suitable  remedy.  When  signs  of  plethora  or  of  con- 
gestion are  present,  blood  is  to  be  taken  from  the  arm,  which  may 
be  repeated  once  or  oftener  if  circumstances  require  it,  particularly 
in  women  in  whom  each  menstrual  period  is  marked  by  an  evident 
molim£n. 

Bleeding  is  certainly  one  of  the  best  means  of  preventing  abor- 
tion ;  but  it  would  be  dangerous  to  conclude  with  the  vulgar,  that 
it  is  useful  in  all  pregnancies  indiscriminately  ;  where  no  particular 
circumstance  calls  for  it,  it  may  be  injurious  to  pregnant  women  as 
well  as  to  other  persons,  and  too  much  fault  cannot  be  found  with 
the  habit  that  some  fall  into  of  being  bled  once  or  twice  during  their 
pregnancy  without  knowing  whether  there  is  any  real  need  for  it 
or  not. 

630.  As  soon  as  the  signs  of  abortion  become  manifest  we  ought 
to  act  in  the  manner  I  shall  point  out  in  the  article  on  uterine  hem- 
orrhagies ;  in  general,  the  most  absolute  rest,  horizontal  posture, 
cold  acidulous  .drinks,  external  revulsives,  applications  of  ice  itself, 
and  anti-spasmodics  and  composing  medicines,  if  there  is  any  agita- 
tion and  tendency  to  convulsions,  will  be  successively  tried  ;  blood- 
letting is  stiH  the  most  powerful  resource  to  be  made  use  of,  but 


ABORTION.  243 

nevertheless  it  is  not  to  be  employed  without  reserve  and  caution,  for  as 
it  does  not  always  prevent  miscarriage,  it  is  liable  to  be  charged  with 
the  production  of  an  accident  which  it  was  impossible  for  it  to  pre- 
vent 'y  bathing  the  feet,  the  hands,  and  the  whole  bath  should  be 
avoided  while  there  is  any  hope  remaining  of  being  able  to  avoid 
the  expulsion  of  the  ovum  ;  otherwise  they  may  be  used  with  ad- 
vantage. 

631.  Where  the  hemorrhage  is  of  an  alarming  character,  we 
have  a  precious  resource  in  the  tampon,  which  has  been  too  much 
neglected  by  the  moderns  ;  it  not  only  often  arrests  flooding,  but  be- 
sides this,  it  does  not  always  hinder  pregnancy  from  going  to  its  full 
term,  as  noticed  by  Gallandat,  M.  Desormeaux  and  Madame  Lacha- 
pelle.  Denman,  Kok,  and  Kluyskens  have  spoken  highly  of  its  em- 
ployment in  such  circumstances  ;  and  like  M.  Hervez  de  Chegoin 
who  makes  frequent  use  of  it,  I  for  my  part  have  nothing  to  say,  ex- 
cept what  is  wholly  in  favour  of  its  employment.  Perhaps  also  the 
ergot  might  be  efficacious  in  such  cases  ;  but  as  it  favours  the  ex- 
pulsion of  the  ovum,  it  would  not  be  prudent  to  make  use  of  it  until 
after  having  tried  all  other  means.  Finally,  when  abortion  is  once 
decided,  it  requires  the  same  cares  as  hemorrhage,  properly  so 
called,  or  as  convulsions. 

632.  To  promote  the  expulsion  of  the  product  of  conception, 
when  the  impossibility  of  retaining  it  in  the  womb  is  once  ascertain- 
ed, we  continue  the  use  of  the  same  means  ;  if  the  woman  is  strong 
we  recur  to  bloodletting  ;  but  rest  and  the  horizontal  posture  are 
less  indispensable  ;  baths  and  ergot  may  be  administered  without  fear. 
Opium  administered  internally  if  the  pains  are  very  strong ;  seda- 
tive ointments,  or  ointment  of  belladonna  applied  to  the  cervix,  if  that 
part  is  painful,  and  in  a  state  of  spasmodic  constriction  ;  and  emol- 
lient injections  into  the  vagina  may  be  of  use  in  some  cases.  If  the 
ovum  is  too  long  in  passing  through  the  cervix,  it  may  be  of  advan- 
tage to  insert  the  finger  into  that  part  and  thus  assist  in  the  expul- 
sion ;  but  we  should  not  determine  to  remove  it  with  the  pinces  a 

faux  germe  of  Levret,  the  placenta  hook  of  Dewees,  nor  any  other 
instrument,  unless  there  should  be  a  pressing  necessity  to  deliver 
the  woman  at  once,  for  we  run  the  risk  of  not  getting  the  whole 
away,  and  of  being  unable  subsequently  to  reach  the  remaining  por- 
tions which  could  not  be  seized  at  first. 

633.  After  the  escape  of  the  foetus,  every  thing  returns  to  its  na- 
tural state,  just  as  it  does  after  a  lying-in.  The  deliverance  of  the 
placenta,  the  milk  fever,  and  the  sequela  of  the  labour  require  the 
same  cares,  particularly  if  the  pregnancy  have  exceeded  the  fourth 
month,  and  even  in  the  first  months,  when  the  ovum  comes  away 


244  "^HE  FOETUS. 

whole ;  but  if  the  membranes  are  left  behind  after  the  expulsion  of 
the  fcetus  or  embryo,  as  they  compose  the  chief  portion  of  the  pro- 
duct, the  consequences  do  not  always  terminate  at  once  ;  in  such 
cases  we  can  never  feel  secure  until  after  their  complete  expulsion, 
and  it  would  be  wrong  not  to  extract  them  as  soon  as  it  is  possible 
to  seize  them  in  the  vagina*. 


SECTION  2. 

Of  the  Term  of  Gestation^  and  of  Retarded  Births. 

634.  The  natural  duration  of  gestation  in  the  human  species  is 
generally  nine  months,  or  rather  two  hundred  and  seventy  days. 
"  Man  only,"  says  Aristotle,  "  is  born  at  seven,  eight,  nine  or  ten 
months ;  the  last  named  period  is  the  most  common ;  sometimes, 
however,  pregnancy  lasts  until  the  commencement  of  the  eleventh 
month."  According  to  Pliny,  gestation  may  continue  a  whole  year. 
Riolan  thought  he  had  seen  pregnancies  of  twelve,  thirteen,  four- 
teen, fifteen,  and  even  of  eighteen  months.  Kiperus,  according 
to  Millot,  and  Chanvalon  pretend  that  the  duration  of  pregnancy 
varies  according  to  climate.  Heister  thinks  we  may  establish 
that  the  term  of  nine  months  is  the  most  ordinary  one,  and  that 
the  time  fixed  by  nature  is  that  which  elapses  from  the  seventh  to 
the  eleventh  month.  Sennertus  thinks  that  every  birth  should  be 
deemed  regular  that  happens  within  one  year.  Blancard,  Hoff- 
mann, Mauriceau,  Schenk,  and  De  la  Motte  have  related  cases 
confirmatory  of  the  opinion  of  Heister.  Levret  contents  himself 
with  advancing  that  the  woman  most  commonly  carries  the  child 
nine  months,  that  many  exceed  that  term,  but  that  few  go  beyond 
the  tenth  month. 

G35.  In  a  cause  that  was  pleaded  by  the  celebrated  lawyer  Gerbier, 
the  duration  of  pregnancy  suddenly  gave  rise  to  some  very  animated 
discussions,  about  the  middle  of  the  last  century. 

Haller,  Berlin,  Lieutaud,  A.  Petit  especially,  and  Lebas,  Vicq- 
d'Azyr,  and  Roussel,  who  were  partisans  of  protracted  pregnancy, 
were  vigorously  opposed  by  Bouvart,  Mahon,  Hebenstreit,  and 
Louis.  The  latter  author  had  no  difficulty  in  demonstrating  that 
the  numerous  histories  of  protracted  pregnancies  mentioned  by  his 
antagonists  prove  nothing  in  the  present  case,  and  that  women  scarcely 
ever  know  the  precise  period  at  whicli  they  were  fecundated  ;  but  he 
was  wrong  to  appeal  to  the  immutability  of  the  laws  of  nature,  and 

♦  See  the  article  on  Delivery  of  the  Placenta. 


DURATION  OF  PREGNANCY.  245      J 

the  necessity  of  not  interfering  with  social  order.     "If,"  cried  he     ' 
in  his  enthusiasm,  "  you  add  to  the  means  women  already  possess       ^ 
of  deceiving  those  about  them,  the  faculty  of  giving  posthumous  chil- 
dren to  their  husbands  whenever  they  choose,  what  will  become  of  the     '^ 
order  of  succession,  and  even  of  the  entire  social  order  ?"     As  if,  in 
the  natural  sciences,  we  ought  not  to  seek  after  truth  rather  than 
concern  ourselves  about  social  conventions  !     On  the  other  hand, 
Petit  and  Lebas  too  complaisantly  admitted  as  proved  what  was  not 
even  in  every  instance  probable ;  so  that  in  spite  of  the  numerous 
analogies  with  which  they  fortified  their  opinions,  the  question  re- 
mained undecided  both  by  naturalists  and  physicians. 

636.  At  present  the  state  of  the  case  is  changed  ;  the  antagonists 
of  Petit  relied  chiefly  on  the  circumstance  that,  according  to  Aris- 
totle, "  the  period  of  gestation  in  animals  is  limited  to  a  fixed  space, 
and  the  term  at  which  they  bring  forth  is  not  subject  to  any  varia- 
tion." But  as  Buflbn  had  before  pointed  out,  this  assertion  is  wholly 
false  ;  Millot  speaks  of  a  cow  which  brought  forth  its  calf  five 
days  after  the  term,  and  of  a  cat  that  kittened  nine  days  before  the' 
regular  period.  Besides,  M.  Tessier,  member  of  the  Academy  of 
Sciences,  a  man  whose  honour  and  good  faith  cannot  be  called  in 
question,  has  removed  all  doubt  upon  this  subject. 

He  found  that,  of  one  hundred  and  sixty  cows,  which  commonly 
carry  their  young  nine  months,  as  women  do,  only  three  brought 
forth  on  the  two  hundred  and  seventieth  day  ;  that  fifty  of  them 
went  from  the  two  hundred  and  seventieth  to  the  two  hundred  and 
eightieth  ;  sixty-eight  from  the  two  hundred  and  eightieth  to  the 
two  hundred  and  ninetieth ;  twenty  to  the  three  hundredth,  and 
that  five  of  them  did  not  calve  until  the  three  hundred  and  eighth 
day,  which  is  thirty-eight  days  beyond  the  term.  On  the  other 
hand,  fourteen  of  them  calved  from  the  two  hundred  and  forty-first 
to  the  two  hundred  and  sixty-sixth  ;  so  that  we  find  sixty-seven 
days  betwixt  the  two  extremes. 

Of  one  hundred  and  two  mares,  whose  terra  is  eleven  months, 
three  of  them  foaled  on  the  three  hundred  and  eleventh  day  ;  five 
from  the  three  hundred  and  tenth  to  the  three  hundred  and  thirtieth ; 
forty-seven  from  the  three  hundred  and  fortieth  to  the  three  hundred 
and  fiftieth  ;  twenty-five  from  the  three  hundred  and  fiftieth  to  the  * 
three  hundred  and  sixtieth  ;  twenty-one  from  the  three  hundred  and 
sixtieth  to  the  three  hundred  and  seventieth  ;  and  one  on  the  three 
hundred  and  ninety-fourth  day,  which  gives  a  latitude  of  eighty-three 
days. 

637.  Thus,  far  from  being  fixed,  the  duration  of  pregnancy  in 
brutes  is,  on  the  contrary,  extremely  variable,  and  as  the  habits  and 


246  THE  FtETUS. 

constitutions  of  women  render  them  incomparably  more  liable  to 
impressions  than  any  of  the  inferior  species  of  animals,  it  is  evident 
they  must  be  liable  to  the  same  irregularities.  Besides,  the  follow- 
ing proof  taken  in  the  human  species,  and  admitting  of  no  reply,  is 
related  by  M.  Desormeaux.  A  lady,  the  mother  of  three  children, 
was  seized  with  insanity  in  consequence  of  a  severe  fever,  and  all 
the  resources  of  hygieine  and  therapeutics  had  been  exhausted  upon 
her  case  in  vain  ;  a  physician  thought  that  a  new  pregnancy  might 
perhaps  restore  her  intellectual  faculties.  The  husband  consented 
to  note  down  in  a  register  the  day  of  each  sexual  union,  which  took 
place  only  once  every  three  months,  so  as  not  to  interfere  with  any 
still  imperfect  conception.  Now,  this  lady  who  was  watched  by  her 
servants,  and  who  was  moreover  endowed  with  very  severe  princi- 
ples both  of  morality  and  religion,  was  not  confined  until  the  lapse 
of  nine  months  and  a  half. 

Being  agitated  anew  in  a  celebrated  cause  before  the  house  of 
Lords,  at  London,  in  1825  and  1826,  this  question  was  decided  in 
the  affirmative  ;  but  the  physicians  did  not  agree  upon  a  fixed  term 
which  must  be  always  admitted.  Out  of  twenty-five  who  were  ex- 
amined, seventeen  said  that  pregnancy  terminates  about  the  thirty- 
ninth  or  fortieth  week,  or  betwixt  the  two  hundred  and  seventieth 
and  the  two  hundred  and  eightieth  day  ;  but  some  of  them  did  not 
consider  the  case  of  Elizabeth  Adderley,  the  wife  of  lord  Hyde 
Gardner,  who  was  brought  to  bed  on  the  three  hundred  and  eleventh 
day,  as  impossible.  Dr  Blundell  mentioned  one  pregnancy  of  two 
hundred  and  eighty-seven  days.  Dr  Merriman  said  he  had  seen 
several  of  two  hundred  and  eighty-five  and  two  hundred  and  eighty- 
seven  days  ;  two  or  three  of  two  hundred  and  ninety-six,  one  of 
three  hundred  and  three,  and  one  of  three  hundred  and  nine  days. 
Dr  Dewees  relates  one  where  tie  woman  was  not  delivered  until 
the  two  hundred  and  ninety-third  day,  &c.  To  these  testimonials 
I  may  add  a  case  which  fell  under  my  own  notice.  A  woman  in 
her  fourth  pregnancy  computed  that  she  was  four  months  gone 
when  she  came  to  my  amphitheatre.  I  distinctly  felt  both  the  active 
and  passive  motions  of  the  foetus.  Appearances  of  labour  took 
place  at  the  end  of  the  ninth  month,  were  soon  suspended,  did  not 
return  for  thirty  days,  languished  a  whole  week,  so  that  in  fact  the 
delivery  did  not  take  place  until  the  three  hundred  and  tenth  day. 

63C.  We  may  therefore  conclude  that  tardy  births  are  incontesta- 
ble ;  but  that  in  the  present  state  of  our  knowledge  it  is  not  possi- 
ble to  affix  to  ihem  any  precise  limits.  Moreover,  since  the  French 
code,  in  order  to  do  away  anything  arbitrary  in  the  decision  on  such 
cases,  has  determined  that  the  legitimacy  of  a  birth  may  be  con- 


DURATION  OF  PREGNANCY.  247 

tested  when  it  occurs  after  the  three  hundredth  day,  or  the  tenth 
month,  this  point  of  physiology  has  lost  much  of  its  importance  ; 
for  at  present  what  is  essential  for  the  physician  .to  know  is,  whether 
a  child  can  or  cannot  remain  longer  than  nine  months  in  the  womb. 


SECTION  3. 
Of  Precocious  or  Early  Births. 

639.  If  fruits  ripen  sooner  in  certain  climates  and  years  than 
others,  if  the  appearance  of  flowers,  if  vegetation  generally  may  be 
more  advanced ;  if  the  hatching  of  the  chick  varies  from  the  nine- 
teenth to  the  twenty-first  day,  or  even  from  the  eighteenth  to  the 
twenty-second  ;  if  some  cats  who  carry  their  young  only  nine  weeks, 
may  bring  them  forth  nine  days  before  their  term ;  if  out  of  one 
hundred  and  sixty-two  cows,  fourteen  of  them  calve  from  the  two 
hundred  and  forty-first  to  the  two  hundred  and  sixty-sixth  day ;  if 
out  of  one  hundred  and  two  mares,  six  of  them  foal  from  the  three 
hundred  and  eleventh  to  the  three  hundred  and  twenty-sixth  day, 
while  their  natural  term  is  three  hundred  and  thirty  days  ;  if  sows, 
rabbits,  &c.  exhibit  the  same  variety,  wherefore  may  not  the  dura- 
tion of  human  pregnancy  be  also  advanced  or  abridged  in  the  like 
manner  ?  I  do  not  see  that  any  thing  reasonable  can  be  objected 
against  the  possibility  of  precocious  or  early  births. 

640.  Every  body  knows  that  one  foetus  is  sometimes  better  grown 
and  stronger  at  six  months  than  another  at  seven  or  more  ;  that  a 
child  at  term  is  sometimes  not  so  stout  nor  tall  as  another  which  is 
only  of  seven  or  eight  months  gestation,  that  on  this  point  the  de- 
velopment of  the  ovum  exhibits  varieties  that  are  almost  infinite  ; 
that  the  changes  that  take  place  in  the  organization  of  the  womb, 
from  the  period  of  fecundation  onwards,  tend  to  develope  in  it  a 
force  similar  to  that  which  directs  the  action  of  the  muscles  ;  that, 
except  in  case  of  accidents,  parturition  is  not  effected  until  this  force 
attains  such  a  degree  as  that  the  uterus  may  contract  with  the 
utmost  force  of  which  it  is  susceptible ;  which  necessarily  takes 
place  sooner  or  later,  according  to  an  infinitude  of  circumstances; 
all  these  things  are  known,  I  say,  and  shall  anyone  dare  to  maintain 
that  precocious  births  are  impossible ! 


248 


CHAPTER  V. 
Of  Labour. 

When  gestation  has  passed  through  all  its  stages,  when  the 
ovum  has  attained  its  last  degree  of  maturity,  and  the  organism  of 
the  foetus  is  sufficiently  perfect  to  enable  it  to  live  independently  of 
the  mother,  the  birth  of  man  takes  place,  and  this  is  the  phenomenon, 
the  fifth  of  the  great  function  of  reproduction,  which  is  called  labour. 

It  has  been  recommended  at  different  times  to  replace  the  word 
accoucJiement  derived  from  ad  and  cubare,  placed  near  to,  by  that 
of  parturition,  derived  from  partus^  partio,  parturire^  or  by  that  of 
chM-h\rth,  puerperium ;  but  as  custom  cannot  give  place  to  a  false 
or  erroneous  acceptation,  these  different  substitutes  have  not  been 
adopted*. 

Definitions.  Levret  has  defined  labour  as  a  natural  operation,  truly 
mechanical,  and  susceptible  of  geometrical  demonstration  ;  which  is 
neither  figuratively  nor  really  true.  Astruc,  imbued  with  the  same 
notions,  thought  he  could  reduce  the  art  of  delivery  to  the  solution 
of  the  following  problem  :  "  An  extensible  cavity  of  a  certain  capa- 
city being  given,  to  extract  therefrom  a  flexible  body  of  a  given 
length  and  size,  through  an  opening  which  is  dilatable  to  a  certain 
extent."  As  if  it  were  a  matter  of  indifference  whether  the  foetus 
should  be  extracted  artificially,  or  whether  its  expulsion  should  be 
left  to  the  powers  of  nature !  Baudelocque  also  has  said  that  labour 
is  a  purely  mechanical  operation,  subjected  to  the  laws  of  gravity 
and  motion ;  as  if  it  were  possible  to  make  precise  calculations  of 
organic  actions,  by  reasoning  upon  the  laws  that  govern  the  physical 
world  !  In  asserting  "  that  labour  is  nothing  more  than  the  passing 
of  the  child  and  its  appendages  from  the  womb,"  M.  Maygricr  also 
employs  a  faulty  definition,  inasmuch  as  it  does  not  express  the  ac- 
tion which  occasions  this  passage.  Neither  is  it  correct  to  say,  with 
Madame  Boivin,  that  labour  is  the  emission,  expulsion,  or  excretion 
of  a  living  child  at  full  term,  together  with  its  appendages,  occasion- 
ed by  the  contraction  of  the  uterus,  and  the  disposition  of  the  genital 

•  In  France. 


OF  LABOUR.  249 

organs  of  the  mother.  This  definition,  in  the  first  place,  is  incon- 
venient, in  being  too  long  ;  and  then  it  comprises  only  natural  labours, 
and  does  not  embrace  either  precocious  or  retarded  births,  nor  cases 
in  which  the  child  is  dead  in  utero.  According  to  M.  Desormeaux, 
who  has  properly  felt  the  insufficiency  of  the  principles  of  Levret, 
Astruc  and  Baudelocque,  "  labour  is  a  function  which  consists  in 
the  expulsion  of  a  foetus  from  the  womb,  in  which  it  grew  during 
the  whole  time  of  gestation."  By  substituting  for  the  words  opera- 
tion and  escape  those  of  function  and  expulsion,  this  able  practi- 
tioner has  rendered  his  definition  incomparably  better  than  any  that 
existed  before.  However,  were  it  of  any  great  consequence  in  prac- 
tice to  adopt  one  definition  rather  than  another,  I  should  prefer 
simply  to  say,  that  labour  is  a  function  that  consists  in  the  expulsion 
of  the  ovum  from  the  ynother^s  organs. 

641.  By  making  use  of  the  word  operation^  physicians  have  gra- 
dually become  accustomed  to  Bee  in  labour  a  phenomenon  almost 
wholly  foreign  to  the  economy;  and  thence  their  eagerness  to  ter- 
minate an  action  which  did  not  require  their  assistance ;  by  admit- 
ting, on  the  contrary,  that  labour  is  a  function,  we  feel  ourselves 
naturally  prompted  to  let  nature  act,  whom  we  assist,  but  whose 
place  we  carefully  abstain  from  taking,  except  in  cases  where  we 
have  before-hand  ascertained  with  mathematical  precision  that  the 
resources  of  nature  are  incompetent. 

642.  Classificaii&n.  Many  plans  have  been  proposed  for  the 
classification  of  labours  ;  Mauriceau,  adopting  the  sentiment  of  Hip- 
pocrates, calls  those  natural  labours  in  which  the  child's  head  pre- 
sents, and  which  terminate  without  assistance ;  all  others  he  calls 
preternatural.  Peu  makes  use  of  the  word  laborious  instead  of 
preternatural.  De  la  Motte  describes  them  as  natural,  non-natural, 
preternatural  and  untoward.  Soon  afterwards  were  admitted,  under 
the  title  of  natural  labours,  all  those  in  which  the  head  or  the  breech 
presented  ;  under  that  o^  laborious,  those  which,  notwithstanding  the 
favourable  position  of  the  foetus,  are  so  long  protracted  that  we  are 
obliged  to  assist  them  ;  all  those  were  called  preternatural  in  which 
neither  the  head  nor  the  breech  presented  to  the  strait.  Smellie 
modified  this  classification,  and  said,  "  I  call  that  a  natural  labour  in 
which  the  head  presents,  and  the  woman  is  delivered  by  her  pains 
and  the  assistance  commonly  given :  but  should  the  case  be  so  tedious 
and  lingering  that  we  are  obliged  to  use  extraordinary  force  in 
stretching  the  parts,  extracting  with  the  forceps,  or  (to  save  the 
mother's  life)  in  opening  the  head  and  delivering  with  the  crotchet, 
I  distinguish  it  by  the  appellation  of  laborious  :  and  in  the  preter- 
natural, comprehend  all  those  cases  in  which  the  child  is  brought 

2G 


250  OF  LABOUR. 

by  the  feet,  or  the  body  delivered  before  the  head."  Smellie's  divi- 
sion, taught  at  the  same  time  by  Astruc,  adopted  by  Solayres,  and 
propagated  by  Baudelocque,  is  still  follov^ed  by  a  majority  of  French 
accoucheurs. 

643.  There  are  few  authors,  however,  who  have  not  attempted  to 
show  its  incorrectness,  and  readily  succeeded  in  doing  so ;  but  as 
those  which  have  been  proposed  as  substitutes  are  not  less  incon- 
venient, it  has  preserved  at  least  the  advantage  of  being  more  gene- 
rally known  than  any  other. 

It  would  be  quite  as  well  to  follow  it,  for  example,  as  with  Millot, 
to  admit  of  a  division  into  natural  labours,  properly  so  called  (the 
child  presenting  the  head)  ;  irregular  natural  labours  (the  child 
coming  breech  foremost) ;  artificial  labours  (those  which  require 
the  employment  of  th*  hand,  either  alone,  or  armed  with  some  in- 
strument, but  without  any  necessity  for  dividing  the  mother's  parts)  ; 
preternatural  labours  (where  it  is  necessary  to  make  an  artificial 
passage  for  the  child) ;  or,  with  M.  Gardien,  to  admit  of  mixed 
labours  (where  the  position  of  the  fcEtus  only  requires  to  be  changed); 
or  with  MM.  Maygrier  and  Gardien,  and  Madame  Boivin,  to  make 
a  division  of  artificial  labours  (preternatural  and  laborious  labours); 
with  M.  Capuron,  mechanical  labours  (where  recourse  is  had  to 
instruments),  or  manual  labours  (the  preternatural  of  Baudelocque); 
or  to  make  along  with  Denman  a  fourth  class,  under  the  title  of 
anomalous  labours  5  or  with  Burns,  to  establish  seven  classes  to 
confuse  every  thing:  1.  Natural  labour;  2.  Premature  labour; 
3.  Preternatural  labour ;  4,  Tedious  labour ;  5.  Instrumental  la- 
bour ;  6.  Impracticable  labour  ;  7.  Complicated  labour.  In  fact 
these  accoucheurs  have  only  changed  the  acceptation  of  the  terms 
they  employ,  or  the  new  ones  they  propose  are  still  more  faulty  than 
the  old  ones,  and  I  cannot  perceive  that  the  modifications  adopted 
by  MM.  Herman  of  Berne,  and  Dewees  of  Philadelphia,  obviate  this 
inconvenience.  Besides,  there  is  no  such  thing  as  a  labour  purely 
artificial,  and  the  student  cannot  at  a  first  glance  understand  the  dif- 
ference between  a  manual  and  a  mechanical  labour,  any  better  than 
that  between  preternatural  and  laborious  labours. 

The  division  that  I  prefer  approaches  very  nearly  to  the  one  in- 
dicated by  Mauriceau.  All  labours  that  terminate  under  the  sole 
influence  of  the  powers  of  the  organism,  after  the  manner  of  M. 
Lebrcton,  I  call  spontaneous^  fortunate  or  simple  ;  those,  on  the  con- 
trary, that  present  difficulties  of  what  nature  soever,  and  which  in 
any  way  endanger  tlie  life  or  the  heallhof  the  mother  or  of  the  child, 
I  call  difficult,  troublesome  or  complicated  ;  and  each  of  these  great 
classes  may  in  turn  be  divided  into  orders,  genera,  species  and  va- 
rieties, if  the  wants  of  the  science  call  for  it. 


OF  IJVBOUR. 


251 


TABLE  I. 


DIVISION  OF  LABOURS. 


Bavdelocque. 
5  Classes. 


1.  Natural  labours.  Re- J 
quiring  no  assistance,  i 

2.  Preternatural  labours.  J 
Requiring  the  use  of: 
the  hand.  ' 

3.  Laborious  labours.  ] 
Requiring  the  use  ofj 
instruments.  ^ 


'I.  Positions  of  the  vertex. 

2.  Positions  of  the  feet. 

3.  Positions  of  the  knees. 

4.  Positions  of  the  breech. 

1.  Faulty  positions. 

2.  Accidents  during  labour. 

1 1.  Faults  of  the  female  organs 
•  2.  Monstrosity  of  the  foetus. 
1 3.  Want  of  power  of  the  organs 


Mm.  Dubois  and"l 

Desormeattx.    1  Like  those  of  Battdelocque.     Presentations  of  the  face 
Mesd.  BoiviN  and  |      are  classed  among  the  natural  labours. 

Lachapelle.    J 


The  Author. 
2  Classes. 


'1.  Eutocia. 


2.  Dystocia,    i 


t.  The  vertex 

2.  The  face. 

3.  The  pelvis. 

1.  Hemorrhagic 

2.  Convulsive. 

3.  Aneurismal. 

4.  Hernial. 

5.  With  procidentia. 

6.  From   disease  of 
woman. 

7.  From    narrowness 
the  pelvis. 

8.  From  wrong  positions, 

9.  From  exhaustion,  &c.  ^ 


All   labours  that  termi- 
nate spontaneously, 


the 
of 


All  labours  re- 
quiring  : 
sistancs. 


ARTICLE  L 


Oy  Labour  in  General. 


644.  Labour  is  said  to  be  at  term  or  timely  if  it  takes  place  at  the 
Rinth  month  of  pregnancy ;  tardy  or  retarded,  if  the  pregnancy  ex- 
tends beyond  this  period ;  advanced,  hastened,  precocious  or  prema^ 
ture,  if  it  takes  place  between  the  seventh  and  the  ninth  months ; 
and  it  is  called  miscarriage  or  abortion  if  it  occur  previously  to  the 
seventh  month.  As  it  is  in  some  sort  produced  by  the  same  causes, 
and  accompanied  with  the  same  phenomena  in  all  cases,  I  shall  first 
examine  it  in  a  general  manner  before  entering  into  details  tipoq 
each  class  in  particular. 


252  OF  LABOUR. 

SECTION  1, 

Of  the  Causes  of  Labour. 

646.  It  is  common  to  divide  the  causes  of  labour  into  proxi- 
mate and  remote,  or  also  into  occasional  or  determining,  and  effi- 
cient or  immediate, 

§.  I.  Efficient  causes. 

646.  The  efficient  causes  are  those  which  effect^  or  properly  speak- 
ing, constitute  {font)  labour ;  they  have  greatly  occupied  the  attention 
of  physiologists  and  accoucheurs  in  all  ages  ;  they  have  by  turns  been 
attributed  to  the  foetus,  the  womb,  the  abdominal  muscles,  the  dia- 
phragm, and  sometimes  to  all  these  parts  together,  Hippocrates 
and  most  of  the  ancients  thought  that  at  the  end  of  gestation  the 
fcEtus  tears  the  membranes,  extends  itself  like  a  spring,  and  pushes 
with  its  feet  and  breech  against  the  fundus  of  the  uterus,  while  with 
its  head  it  presses  upon  the  cervix  so  as  to  dilate  it,  pass  through  it, 
and  then  escape  from  the  genital  organs.  This  opinion,  which  still 
prevails  amongst  the  vulgar,  was  founded  upon  what  takes  place  in 
birds,  where  the  little  chick,  for  example,  breaks  the  surrounding 
shell  with  its  beak,  when  it  reaches  the  period  of  hatching ;  upon 
the  circumstance  that  children  that  die  while  in  the  womb  are  born 
with  more  difficulty  than  those  who  are  strong  and  vigorous;  and 
lastly,  on  the  fact  that  children  have  been  frequently  known  to 
escape  spontaneously  from  the  womb  after  the  death  of  the  mother. 

647.  Nevertheless,  it  has  never  been  generally  admitted  that  the 
foetus  is  the  sole  agent,  the  sole  efficient  cause  of  delivery  ;  indeed, 
the  wisest  authors  believed  that  it  played  an  important  part  in  this 
grand  function  ;  but  that  it  could  not  come  forth  without  calling 
other  powers  to  its  aid.  In  this  respect  the  opinion  of  the  moderns 
is  entirely  opposed  to  that  of  the  ancients.  During  the  process  of 
its  birth  the  foetus  does  not  exert  in  any  way  an  active  power ;  the 
analogy  which  it  was  attempted  to  trace  between  child-birth  and  the 
hatching  of  a  chick  cannot  withstand  the  very  weakest  objection  :  in 
most  cases  the  d(3ath  of  the  child  does  not  affect  its  expulsion  at  all ; 
besides,  the  slowness  of  the  labour  in  such  a  case  is  explained  by 
the  fact  that  the  foetus  when  dead  is  ilaccid,  and  cannot  present  to 
the  womb  the  same  firm  resistance  as  if  it  were  alive  ;  that  if  putre- 
faction have  commenced,  the  irritability  and  contractility  of  the 
womb  often  receive  a  mischievous  influence  therefrom,  and  to  a 
greater  or  less  extent  lose  their  natural  vivacity ;  finally,  that  the 


CAUSES  OF  LABOUR.  253 

vitality  of  the  fetus  being  generally  proportioned  to  that  of  the  organ 
in  which  it  is  contained,  it  is  quite  natural  that  the  labour  should  be 
more  prompt  and  easy  where  the  child  is  robust  and  healthy  than 
where  it  is  feeble  or  diseased. 

648.  Those  labours  that  sometimes  take  place  after  the  death  of 
the  woman,  and  form  the  principal  argument  of  the  partisans  of  the 
ancient  hypothesis,  furnish  on  the  contrary  a  decisive  proof  in  sup- 
port of  the  opposite  doctrine.  In  these  cases  the  children  have 
always  been  found  lifeless  between  the  mother's  legs;  it  might  even 
be  affirmed  that  they  died  first.  They  escape  from  the  womb  by 
means  of  a  power  wholly  extrinsic  to  them  ;  after  death,  the  organs  of 
the  life  of  relation,  especially  the  muscles,  become  relaxed,  while 
those  of  vegetative  life  continue  for  some  time  in  possession  of  their 
contractility ;  sometimes  the  abdomen  becomes  filled  with  gas  with 
surprising  rapidity  ;  so  that  if  the  labour  is  far  advanced  when  the 
woman  dies,  it  is  not  a  surprising  matter  that  the  uterus,  being  me- 
chanically compressed  from  without,  meeting  with  no  further  resis- 
tance from  the  perineum,  and  still  retaining  the  power  of  contraction, 
is  enabled  completely  to  expel  the  ovum  without  any  necessary  par- 
ticipation on  the  part  of  the  foetus.  This  was  evidently  the  nature 
of  the  case  with  the  woman  named  Homer,  who  gave  birth  to  a  dead 
child,  thirty-four  hours  after  she  had  herself  ceased  to  exist. 

649.  In  the  second  place,  observation  has  demonstrated  that  de- 
livery takes  place  pretty  nearly  in  the  same  manner  whatever  be  the 
period  at  which  it  happens  :  now,  where  abortion  takes  place  in  the 
first  half  of  the  period  of  utero-gestation,  it  is  evidently  impossible 
for  the  foetus  to  make  the  least  effort  to  escape  from  the  organs. 
How  can  so  delicate  a  creature  be  supposed  capable  of  dilating  an 
opening,  through  which  the  most  vigorous  man  might  vainly  essay  to 
pass  his  hand  ?  Who  does  not  know  that  until  the  fourth  or  fifth 
month  it  is  scarcely  capable  of  making  a  few  motions ;  that  it  is 
rarely  strong  enough  to  be  born  alive,  or  at  least  to  live  over  a  few 
minutes  after  birth  ?  Were  it  to  act  of  itself  in  labour,  it  would  com- 
mence by  rupturing  the  membranes  :  however,  the  bag  of  waters  is 
not  broken  until  the  last  stage  of  labour ;  in  some  cases  it  does  not 
break  at  all,  and  the  ovum  comes  away  whole  ;  besides,  the  very 
moment  when  the  bag  of  membranes  presses  upon  the  cervix  in 
order  to  engage  in  it,  is  the  time  when  tlie  foetus  retires  from  it, 
instead  of  pressing  upon  it.  If  it  be  true  that  the  birth  of  a  dead  or 
very  feeble  child  is  generally  effected  more  slowly  than  that  of  a 
foetus  that  is  strong  and  full  of  vigour,  it  is  also  true,  that  the  differ- 
ence between  the  birth  of  a  living  and  dead  one  is  not  sensible. 
In  all  cases,  the  after-birth  comes  away  at  last,  and  we  are  compelled 


254  CAUSES  OF  LABOUR. 

to  agree  that  the  action  of  the  foetus  has  nothing  to  do  with  that. 
Let  the  head,  the  trunk,  or  any  separate  part  be  left  in  the  womb, 
and  it  will  be  expelled,  just  as  if  the  foetus  were  whole,  and  living. 
The  placenta,  the  membranes,  the  clots,  the  whole  after-birth,  a 
mole,  a  fibrinous  concretion,  a  polypus,  and  all  kinds  of  bodies, 
in  short,  that  are  met  with  in  the  womb  are  incapable  of  any  spon- 
taneous action,  and  yet  their  expulsion  is  effected  by  the  same  laws, 
and  announced  by  the  same  phenomena  as  those  of  the  most  robust 
and  the  healthiest  foetus.  It  is  therefore  undeniable  that  the  foetus  is 
not  the  efficient  cause  of  labour ;  that  instead  of  performing  a  part 
(essentially  active  in  this  process,  it  is  on  the  contrary  completely 
passive  from  the  beginning  to  the  end  of  it. 

650.  This  cause  should  be  sought  for  in  the  organs  of  the  mother, 
which  was  not  done  until  in  the  last  century.  Galen,  J.  Fabricius, 
Gelee,  Harvey,  Levret,  &c.  had,  it  is  true,  already  maintained  that 
delivery  is  effected  under  the  influence  of  the  contractions  of  the 
uterus,  the  abdominal  muscles,  and  diaphragm  ;  but  this  opinion,  be- 
ing vaguely  expressed,  did  not  have  any  effect  on  the  theory  of  par- 
turition. Besides,  Haller  thought  that  the  womb  is  but  a  secondary 
agent,  and  that  the  abdominal  muscles  and  diaphragm  are  the  chief 
agents.  To  A.  Petit  was  reserved  the  glory  of  demonstrating  be- 
yond dispute,  that  the  efficient  cause  of  labour  is  essentially  consti- 
tuted by  the  contractions  of  the  uterus,  and  partly  by  those  of  the 
muscles  of  the  abdomen  and  thorax. 

651 .  Essential  efficient  cause.  We  acquire  by  direct  observation 
the  proof  that  the  contractions  of  the  uterus  constitute  the  efficient 
principle  of  labour.  By  applying  the  hand  upon  the  epigastrium 
during  a  pain,  the  womb  is  felt  to  grow  hard,  to  shrink,  to  lessen 
in  size,  in  one  word,  to  contract ;  the  finger,  when  introduced  into 
the  vagina,  perceives  the  orifice  to  become  stretched,  to  grow  thin, 
and  dilate  or  contract  according  to  the  stage  of  the  labour.  As 
soon  as  the  pain  ceases,  nothing  of  this  sort  can  be  perceived ;  all 
the  parts  become  relaxed  ;  as  soon  as  it  returns,  all  the  phenomena  of 
contraction  reappear  ;  but  it  is  particularly  when  we  are  compelled, 
in  performing  some  operation,  to  introduce  the  hand  into  the  interior 
of  the  womb,  that  we  abandon  all  doubt  as  to  the  important  part 
which  it  performs  in  the  expulsion  of  the  ovum.  It  pretty  often 
happens  here  that  the  operator  is  obliged  not  only  to  suspend  his 
progress  during  each  contraction,  but  he  also  sometimes  loses  for  a 
short  ppace  all  sensibility,  all  power  to  act,  and  the  hand,  which  is 
benumbed,  and  as  it  were  paralyzed,  becomes  incapable  of  distin- 
guishing the  objects  it  touches.  What  practitioner  has  not  had 
•occasion  to  see  that  it  is  not  possible,  during  a  pain,  to  pass  through 


CAUSES  OF  LABOUR.  255 

the  03  uteri  ?  Who  does  not  know,  that  when  passed  up  to  search 
for  coagula,  the  placenta,  or  the  fetus  itself,  the  hand  is  soon 
forcibly  expelled,  together  with  the  foreign  body  it  was  designed  to 


remove 


652.  Strictly  speaking,  the  contractions  of  the  uterus  might  suf- 
fice for  the  expulsion  of  the  child  ;  in  several  cases  of  complete 
procidentia  of  the  womb,  such  as  those  reported  by  Peu,  Jalouzet  and 
Madame  Lachapelle,  the  pregnancy  has  been  found  to  go  to  the 
full  term,  and  the  labour  to  terminate  spontaneously  ;  many  women 
have  been  unconsciously  delivered  during  an  attack  of  lethargy,  of 
asphyxia,  or  in  a  deep  sleep,  into  which  they  had  fallen  in  conse- 
quence of  criminal  attempts.  Women  weakened  by  protracted  dis- 
ease, a  hemorrhage,  or  exhausted  by  suffering  unconnected  with 
childbirth ;  those  who  are  afiected  with  ascites,  inflammation  in  the 
chest,  delirium,  or  madness  ;  those  whose  abdominal  muscles,  thin 
and  pale,  have  lost  almost  all  their  contractility  ;  such  as  are  pusilla- 
nimous, timid,  excessively  irritable,  or  of  a  very  marked  lymphatic 
constitution  ;  and  lastly,  all  such  as  from  debility,  disease,  want  of 
courage,  excess  of  sensibility,  or  want  of  power,  do  not  bear  down 
at  all,  and  who,  on  the  contrary,  employ  all  the  resources  of  their 
volition  to  arrest  the  least  eflfort  of  their  muscular  system,  are  deli- 
vered notwithstanding.  The  womb  alone  in  such  cases  bears  the 
whole  burthen  of  parturition. 

653.  Accessory  efficient  cause.  Nevertheless,  the  womb  in  most 
cases  requires  to  be  sustained  by  the  action  of  the  diaphragm  and 
abdominal  muscles.  The  concurrence  of  this  action  is  so  evident 
in  most  women  that  no  observer  has  thought  of  denying  its  exist- 
ence, and  that  it  is  sufficient  to  announce  it  as  a  simple  proposition  ; 
but  its  importance  has  not  been  understood  in  the  same  way  by 
all  authors.  According  to  Haller,  the  womb  contracts  only  for 
the  purpose  of  preventing  the  child  from  being  pressed  together 
into  a  confused  mass,  to  force  it  to  present  one  extremity  of  its 
occipito-coccygeal  diameter  to  the  straits ;  by  their  contractions, 
the  abdominal  muscles  support  the  womb  in  front  and  on  its  sides, 
so  as  to  prevent  it  from  deviating,  or  from  abandoning  the  direction 
of  the  axis  of  the  pelvis,  or  bending  in  any  direction,  and  make  it 
in  some  respects  resemble  a  straight  canal,  continuous  with  the 
pelvis.  The  descent  of  the  diaphragm  then  bears  wholly  upon  the 
fundus  of  the  uterus^;  the  cervix,  being  unsupported,  yields  to  the 
effort ;  and  the  foetus,  being  forced  from  above  downwards,  passes 
through  the  genital  organs  as  an  inert  and  solid  trunk,  passing  out 
of  a  long  canal  with  inflexible  parietes. 


256  CAUSES  OF  LABOUR. 

664.  By  carefully  noticing  the  proceedings  of  nature,  it  will  be 
perceived  that  the  idea  of  Haller  expresses  very  well  the  mode  in 
which  the  diaphragm  and  abdominal  muscles  operate ;  but  it  is  in- 
correct, inasmuch  as  it  attributes  to  the  uterus  only  a  secondary 
part,  whereas  it  is  a  matter  of  demonstration  that  its  contractions 
constitute  the  chief  cause  of  delivery.  Upon  this  hypothesis,  the 
expulsion  of  the  ovum  is  almost  wholly  submitted  to  the  volition  of  the 
woman,  but  no  one  is  ignorant  of  the  fact  that  parturition  is  almost 
entirely  involuntary.  Further,  it  was  not  so  much  Haller  himself, 
as  his  commentators,  who  desired  to  limit  in  this  way  the  importance 
of  the  uterine  contractions  ;  for  that  great  man  says  positively,  that 
the  efforts  of  the  woman  are  not  always  indispensable  to  the  termi- 
nation of  the  labour. 

655.  On  the  contrary,  far  from  acting  with  so  much  power  on 
the  womb,  the  diaphragm,  as  has  been  remarked  by  M.  Bourdon, 
only  serves"  as  a  firm  point  d'appui  for  the  abdominal  muscles. 
Whenever  an  effort  is  made,  the  chest  dilates,  the  lungs  fill  with  air, 
after  which  the  glottis  closes  ;  the  diaphragm  gives  to  the  base  of  the 
thorax,  which  is  moreover  supported  within  by  the  distended  lungs, 
a  degree  of  immovableness  and  solidity,  which  affords  to  the  muscular 
powers  a  fixed  point  that  they  could  not  otherwise  have  obtained  ; 
whence  it  follows,  that  it  is  not  by  pressing  the  viscera  from  above 
downwards,  as  is  generally  supposed,  that  the  diaphragm  assists  the 
uterus,  but  rather  by  giving  to  the  chest  the  power  of  resisting  the 
contractions  of  the  abdominal  muscles,  which  contractions  are  thus 
rendered  effective  upon  the  body  to  be  expelled. 

656.  ,In  most  women  the  uterus  is  the  first  and  only  part  to  con- 
tract until  the  foDtus  has  reached  the  excavation  of  the  pelvis.  From 
this  moment  a  sense  of  weight,  of  straining,  or  of  tenesmus,  irre- 
sistibly invites  the  concurrence  of  the  contractions  of  the  abdominal 
muscles.  Whilst  the  sole  object  of  the  womb  is  to  dilate  its  neck,  it 
needs  no  aid  ;  but  when  the  orifice  is  sufficiently  large,  the  foetus 
must  next  be  forced  through  a  firm  and  very  narrow  canal.;  greater 
powers  become  indispensable,  and  the  uterus,  redoubling  its  efforts, 
rarely  fails  to  solicit  the  action  of  all  the  muscles  of  the  body.  The 
head  and  limbs  being  first  fixed,  the  chest  dilated,  the  diaphragm 
depressed,  the  lungs  filled  with  air,  and  the  glottis  closed,  permits 
the  abdominal  parictes,  firmly  attached  to  the  pelvis  and  base  of  the 
thorax,  to  contract  from  before  backwards,  as  well  as  laterally ;  the 
viscera,  being  unable  to  raise  the  phrenic  septum  which  separates 
them  from  the  lungs,  transmit  directly  to  the  fundus  of  the  womb  the 
lively  impression  they  have  received  ;  the  latter  organ,  also  sustained 


CAUSES  OF  LABOUR.  25t 

•oti  all  sides,  now  efficaciously  employs  all  its  powers  to  expel  th6 
foetus  through  the  cervix,  the  only  point  which  now  offers  no  resist* 
ance,  and  upon  which  all  its  efforts  conr)e  to  operate. 

657.  This  is  the  way  in  which  the  process  takes  place  in  a  na^ 
tural  state,  but  the  organism  is  sometimes  obliged  to  take  another 
course;  the  woman  is  not  always  capable  of  effecting  this  combina- 
tion of  actions.  In  certain  cases  the  uterus,  compelled  to  suffice  for 
itself,  sometimes  succeeds  in  producing  the  desirable  result  without 
any  difficulty  ;  but  in  other  cases,  being  too  feeble,  either  in  conse- 
quence of  over  distention^  which  destroys  its  tone  by  reducing  the 
thickness  of  its  walls,  or  of  contractions  too  long  continued  or  too 
frequently  repeated,  or  because  its  function  is  interfered  with  by 
some  modification  of  the  natural  state  of  its  structure,  it  yields  in  im- 
portance to  the  muscles,  which,  if  directed  with  a  vigorous  and  cou- 
rageous will,  are  sometimes  able  to  expel  the  foetus  with  but  a  feeble 
tto-operation  on  the  part  of  the  womb, 

668.  In  this  sense  only  may  labour  be  regarded  as  in  some  cases 
a  partly  voluntary  function,  like  the  excretion  of  stool,  and  the 
emission  of  urine.  Doubtless,  a  woman  who  bears  down,  as  it  is 
called,  who  enforces  her  pains,  no  matter  how  feeble  soever  they 
may  be,  will  get  rid  of  the  product  of  conception  sooner ;  and  that 
another  may,  to  a  certain  extent,  protract  its  expulsion  by  prevent- 
ing as  much  as  possible  the  contraction  of  her  muscles. 

659.  A  woman  presented  herself  at  Baudelocque's  amphitheatre^ 
lo  be  delivered  there ;  the  labour  at  first  went  on  very  regularly  ; 
the  pupils  were  assembled ;  the  dilatation  of  the  orifice  was  suspend- 
ed, and  a  whole  night  passed  away  without  its  making  any  progress ; 
the  spectators,  who  were  fatigued,  now  dispersed ;  the  pains  soon 
returned,  and  the  dilatation  went  on  ;  the  young  people  being  noti- 
fied, reassembled ;  again  the  phenomena  of  the  labour  ceased. 
Baudelocque,  suspecting  the  cause  of  these  irregularities,  gave  a 
hint  to  the  pupils,  who  all  left  the  apartment  with  an  injunction  not 
to  go  far,  and  to  return  upon  the  first  signal ;  the  woman  imme- 
diately began  to  bear  down,  and  the  child's  head  soon  reached  the 
vulva ;  the  pupils  were  then  called,  and  the  labour,  which  it  was 
no  longer  in  her  power  to  suspend,  soon  terminated.  I  witnessed 
a  nearly  similar  case  in  1825.  One  of  the  first  women  that  came 
to  lie  in  at  my  amphitheatre,  had  pretty  smart  pains,  and  the  neck 
of  the  uterus  dilated  regularly  and  promptly  as  long  as  there  were 
only  a  few  pupils  present.  When  they  had  all  assembled,  she  con- 
tinued to  complain  in  the  same  manner,  but  the  labour  did  not  ad- 
vance at  all ;  the  whole  day  and  night  passed  in  this  manner  ;  in  the 
morning  all  the  witnesses  went  away  to  get  some  sleep  ;  the  dilala- 
2H 


258  CAUSES  OF  LABOUR. 

tion  began  again ;  about  noon  it  wad  nm<o  « j 

re.r„e,,  and  .he  phe„o™e»a  we^rX^t""  r^"' 

:ar::;  r:rjtrra"°"r  ^  -  ~c:i 

o'Coc.  a.  „i,ht.  A  fl"  rCa  H"  tr  '""^  '"^'"° 
panied  with  a  sensiblp  HllnfoiJ         ^^j^^^aras,  the  pams  were  accom- 

™.c„ «...  ..arici'^^-r  .„tH:f::L—  "'*- 

before  e  even,  just  as  twn  nf  th^   *  ;>     .  ^*  ^^"  minutes 

sl.e  ,eft  .he  wlf/  .  ,^  Za^  „  ted  Z'f  ''T""'-  ^"""^ 
rid  onhe  s.ude„.,,  and  ,o  iL^Z^^lv'  '""'  T  '°  «" 
tronp      P.,**!,  "^"^^^^  "^^selfaasoon  asthevwerp 

llsh"  „,  if  "■'  T'P"°"'  ""■■'''■  ""  "<"  '■"'ler  "^  from  elb 

«.eabdo„i„aTr:Ll„dt;i^;r'  '""  '""^''  "^  "-^  "^ 

§.  n.  Dcermining  or  occasional  causes. 
660.  When  i.  is  remembered  liow  much  lim.  „,.  •    . 

acquire  correc.no.io„s  concerning  .he  XL.  ""'""^  '" 

ough.  .0  be  fel.  a.  .he  vagueness  of  opinfos",  beT  "" T?"'" 
regard  to  the  de.ermining  causes  of  laZr  Th.  /'T  ""'  '" 
tained  varied  in  accordancn  „i>h  ,?        j     •  "'"'''  *"•"'  ™'er- 

sesof  each  par«cu,afrrio^"Vnd  Jll  "'""  "'"'""'  "^P"""- 
en.er.ai„ed  by  accouche'rlpon''. L  efficLTc?  '°  ""  """""^ 
«.ey  were  referred  .0  .be  fa!.„.;p„,r      ,  """"•■  ^om^'imes 

par.s  of  ,he  mo.ber  ThS  m '  be  d  vM 7",'°  "'  ""'"'' "'  °"'- 
causes,  and  acciden.al  de.llT„gca  t  Cfo"  '^'"""""^ 
have  their  origin  in  the  ovum,  of  in  bTecInomv  oTh"'"'"""'^ 
they  exist  therefore  in  everv  case  »nH  l.  i  """"^  °^  "■«  """nan  ; 
called.  The  latter  are  eLTLm "  "J  1°  '"^"  ""P"'^  » 
ganism,  depend  upon  a  disease  of  the  Iv  '  ol  „  7'""  '"  "^  "'- 
par.icular  predisposition,  &c     Iv  are  T'  .^         ^ '"'  "P°"  """" 

Of  abortion  ;,s,ra,i,i,e;cfo:e.;:r:rfr^^^^^^^^^^^ 

661.  Believing  that  the  frpfnQ  w=«ir  ,      ^"""  "iis  piace. 

escape,  cer.ai„  a^utbo.  Z^::fL:Z^,  o^  raTnit^^ 
come  so  acrid  and  irritatinjr  n,  «*  ine*  *  .  amnios  be- 

..on  Of  .he  .in  ,  .hat  .Xiratr  l^^  ^V^ bjl^^^^^^^ 
sence  of  the  unne  and  meconium,  caused  .be  child  ,o  feel  a  necel 

of  refrcshmenV    th»  i  /  n         ,   ""''  '"''' '"  "'"'  "'■■  "«'  -=»"^ 


DETERMINING  CAUSES.  359 

turity  led  it  to  detach  itself,  as  a  ripe  fruit  falls  from  the  limb  of  a 
tree  ;  and  that  the  circulation  could  not  be  longer  performed  without 
the  action  of  the  lungs.  At  a  first  glance,  it  might  seem  superfluous 
to  repeat  all  these  various  opinions,  since  it  is  actually  demonstrated 
that  the  child  is  not  the  active  agent  of  its  own  escape  ;  but  as  it  has 
been  on  the  other  hand  pretended  that  it  only  puts  the  uterine  con- 
tractions into  play,  under  the  influence  of  the  same  causes  of  uneasi- 
ness, embarrassment  or  necessity,  I  thought  it  best  not  to  pass  them 
over  in  silence. 

662.  In  the  first  place,  all  this  scaffolding  is  supported  on  mere 
suppositions.  As  has  been  said  by  A.  Petit,  no  fluid  in  the  animal 
economy  is  less  acrid  than  the  liquor  of  the  amnios  ;  if  it  ever  does 
acquire  any  irritating  properties,  it  happens  as  often  at  six,  seven, 
or  eight  months  as  at  nine,  and  it  has  never  been  shown  that  the 
pregnancy  in  such  cases  was  advanced  one  single  day. 

663.  The  child  is  so  little  disturbed  by  the  necessity  of  voiding 
its  meconium  or  urine  ;  that  it  sometimes  remains  several  days  after 
birth  without  discharging  them  ;  who  told  it  that  outside  of  its 
place  of  habitation  there  was  air  for  it  to  breathe,  and  to  cool  the 
heat  of  its  blood  ?  The  temperature  of  the  uterine  cavity  is  the  same 
as  that  of  the  rest  of  the  woman's  body,  and  a  thermometer  placed 
there  during  labour,  would  not  rise  any  higher  than  one  held  in  her 
mouth  ;  moreover,  the  experiments  of  M.  Edwards  prove  that,  far 
from  being  burning  hot,  the  temperature  of  the  foetus  is  two  degrees 
lower  than  that  of  the  mother,  as  long  as  it  remains  in  the  womb  ; 
it  is  not  true  that  the  anatomical  disposition  of  the  utero-fcetal  vas- 
cular system  is  at  child-birth  sensibly  different  from  what  it  was  a 
few  weeks  previously  ;  nor  is  it  more  true  that  the  ovum  is  permea- 
ble by  fluids,  or  less  adherent  at  the  end  than  about  the  middle,  or 
even  the  commencement  of  gestation  ;  it  is  an  ingenious  metaphor 
to  say  that  it  separates  like  a  ripe  fruit,  but  nothing  like  explanation 
has  been  thereby  gained. 

664.  But  if  it  be  true  that  the  sudden,  violent  and  convulsive-like 
movements  of  the  child  sometimes  force  the  labour  to  come  on  be- 
fore the  natural  term,  it  is  not  less  true  that  that  is  an  accident 
which  ought  to  be  classed  among  the  causes  of  abortion,  and  that 
labour  most  frequently  comes  on  without  any  thing  of  that  kind  beinff 
noticed.  Neither  can  the  contraction  of  the  ductus  arteriosus,  the 
ductus  venosus,  and  foramen  ovale,  as  they  do  not  take  place  to  the 
same  extent  in  every  fcetus,  be  the  cause  of  a  phenomenon  whose 
period  very  rarely  varies,  and  with  which  variations  it  has  besides 
no  correspondence. 

665.  An  anonymous  author,  who  was  for  a  long  time  opposed  by 


289^  DETERMINING  CAUSES. 

Millot,  speaks  of  a  vacuum  that  takes  place  in  the  sac  of  genera^ 
tion,  in  consequence  of  the  transudation  of  its  waters,  and  pretends 
that  the  uterus,  obeying  its  natural  elasticity,  closes  up  so  as  to  re- 
move this  void  ;  hut  it  is  easy  to  perceive  that  this  author  mistakea 
the  effect  for  the  cause,  and  has  misunderstood  the  question. 

666.  Steinzel  and  others  have  referred  the  occasional  cause  of 
parturition  to  the  periodical  nisus  of  each  menstrual  period.  But 
in  the  first  place  many  pregnant  women  are  met  with,  in  whom  the 
habit  of  menstruation  has  never  been  exhibited.  Now  the  influence 
of  habit  is  felt  so  much  the  more  powerfully  the  nearer  we  are  to  the- 
instant  when  it  was  left  off.  Yet,  in  the  hypothesis  of  Stein,  pre- 
cisely the  contrary  is  remarked.  Besides,  in  order  to  see  at  once 
the  futility  of  such  a  theory,  it  is  merely  necessary  to  advert  to  the 
feet,  that  the  ninth  catamenial  revolution  takes  place  in  some 
females  at  the  commencement  of  the  eighth  month,  in  others  at 
the  seventh,  often  at  the  end  of  the  tenth,  and  that  a  good  many  wo- 
men do  not  menstruate  more  than  two  or  three  times  a  year,  while  the 
differences  observed  in  the  duration  of  pregnancies  are  so  few,  that 
many  persons  still  doubt  as  to  theijr  existence. 

667.  MM.  Lobstein  and  Cliaussier  seem  to  admit  that  this  cause, 
which  has  been  so  much  sought  for,  is  found  in  the  completion  of 
the  organi2>ation  of  the  womb,  which  waits  until  the  muscular 
character  of  its  fibres  is  fully  developed  before  it  contracts.  But 
miscarriages  and  premature  labours  fully  demonstrate  the  insuffici- 
ency of  such  an  explanation. 

668.  According  to  Loder  the  extensibility  of  the  womb  is  con- 
fined within  certain  limits  ;  the  fibres  of  the  womb,  fatigued  by  a 
long  continued  state  of  distention,  being  unable  t«  yield  any  further, 
react,  at  the  end  of  the  ninth  month,  upon  the  body  that  had  kept 
them  so  long  extended,  and  thus  decide  the  act  of  parturition  ;  but 
upon  reflecting  tiiat  the  development  of  the  womb  is  not  a  passive 
j)hcnomenon,  that  twin  pregnancies,  or  those  where  the  ovum  from 
some  cause  attains  to  very  groat  dimensions,  do  not  terminate  any 
.sooner  than  tho.se  where  the  womb  acquires  but  a  very  small  size, 
we  are  compelled  to  reject  tliis  hypothesis  also. 

C>G9.  The  opinion  of  Levret  and  Baudelocquc,  entertained  also 
by  M.  Desormcaux,  has  at  the  present  day  the  greatest  number  of 
partisans.  Founded  on  the  arrangement  of  the  uterine  fibres,  and 
upon  observation  of  the  phenomena  of  pregnancy,  it  has  appeared 
to  bo  more  salif;factory  than  any  otjjer.  It  is  said — if  the  cavity  of 
the  body  of  the  womb, only,  enlarges  dm-ing  the  four  or  five  first 
months,  and  ihal  of  the  cervix  afterwards  dilates  by  degrees,  from 
^.\}0\e  downwards,  and.  confounds  itself  with  the  former,  it  depond.s. 


DETERMINING  CAUSES.  261 

Upon  the  circumstance  that  the  fibres  of  the  body  and  fundus,  placed 
lengthwise,  and  being  the  softest  and  most  extensible,  distend  and 
yield  more  easily  than  those  of  the  neck,  which  are  circular,  denser^ 
more  compact,  and  situated  transversely.  Between  them  is  estab- 
lished a  kind  of  balancing  or  contest,  which  results  in  the  induction 
of  labour  :  those  of  the  body  must  be  looked  upon  as  so  many  loops 
which  embrace  the  ovum  in  their  concavity,  while  their  extremi- 
ties are  attached  to  different  points  of  the  circles  of  the  neck  ;  the 
former  at  first  yield  without  difficulty,  and  even  without  reacting 
upon  the  latter  ;  but  about  the  middle  of  pregnancy,  by  elongating, 
they  stretch  the  fibres  of  the  neck,  whose  circles  disappear  or  are- 
thus  drawn  in  succession  into  the  body  of  the  organ  ;  so  that  at  last 
the  canal  of  the  neck  no  longer  exists,  but  merely  an  orifice  with  a 
circumference  of  greater  or  less  thickness.  There  is  then  an  equi- 
librium between  the  neck  and  body  of  the  womb  ;  but  as  the  looped 
fibres  have  now  no  other  resistance  to  overcome  but  the  circular 
fibres,  they  triumph  over  the  os  uteri  with  great  facility,  the  equili- 
brium is  soon  broken,  and  labour  commences. 

670.  According  to  this  view  of  the  circumstances,  I  should  define 
the  determining  cause  of  labour  to  be,  the  tendency  of  the  fibres  of 
the  body  of  the  uterus  to  contract ;  a  tendency  or  effort  which  pro- 
duces no  real  and  sensible  effect,  until  from  the  moment  when  the 
cervix  ceases  to  furnish  any  further  materials  to  the  enlargement  of 
the  womb. 

671.  A.  Petit  expressed  himself  upon  this  subject  somewhat  dif- 
ferently :  "  It  cannot  be  doubted,"  says  that  author,  "  that  the  deter- 
mining cause  of  the  uterine  contractions  is  the  irritation  experienced 
by  the  uterus  when  pregnancy  has  reached  its  full  term.  I  consider 
the  cervix  as  a  magazine  in  which  nature  has  placed  in  reserve  the 
quantity  of  muscular  fibres  which  she  needs,  to  furnish  by  their  de- 
velopment materials  for  the  expansion  of  the  womb  during  the 
course  of  gestation.  In  the  natural  state  this  expansion,  when  once 
begun,  proceeds  pari  passu  with  the  growth  of  the  foetus  ;  every 
thing  is  proportioned,  fixed,  so  that  when  the  latter  is  sufficiently 
developed  to  bear  the  action  of  external  agents,  and  employ  them 
for  its  own  benefit,  all  the  fibres  of  the  cervix  have  yielded,  and  the 
magazine  is  exhausted  ;  labour  will  therefore  take  place  when  all 
the  fibres  that  had  been  placed  in  reserve  in  different  parts  of  the 
womb,  and  chiefly  in  the  substance  of  the  cervix,  shall  have  been 
employed.  As  long  as  any  of  them  remain,  the  womb  may  go  on 
increasing,  and  no  irritation  will  be  occasioned  ;  a  simple  develop- 
ment is  not  capable  of  producing  it." 

67.2.  This  explanation  is  more  rational  than,  tbfr  Wfsien-iHaftft'or 


262  DETERMINING  CAUSES. 

it  by  Baudelocque.  The  idea  of  a  struggle  between  the  fibres  of 
the  different  points  of  the  uterus  is  doubtless  ingenious,  but  the  fact 
which  it  expresses  has  no  existence  in  nature.  To  me  it  seems  evi- 
dent, that  by  imbibing  fluids  during  the  pregnancy,  the  organ  of 
gestation  is  enabled  to  unfold  its  fibres  in  an  active  manner  ;  that 
this  unfolding  takes  place  first  in  the  body  and  fundus,  because 
there  the  ovura  is  lodged  in  the  commencement ;  that  it  afterwards 
takes  place  in  the  neck  by  the  same  mechanism,  that  is,  by  the  ac- 
*  cumulation  of  liquid  molecules,  which  gradually  separate  the  con- 
stituent molecules  of  the  fibres  ;  that  this  unfolding  being  brought 
to  a  conclusion,  and  the  womb  besides  having  acquired  the  comple- 
ment of  its  muscular  organization,  enters  upon  its  contractile  state 
for  the  purpose  of  expelling  the  body  that  fills  its  cavity,  and  that 
now  begins  to  produce  in  it  a  more  lively  state  of  irritation. 

673.  Miscarriages,  and  premature  labours,  as  well  as  protracted 
gestation,  &.c.  might  be  rigorously  accommodated  to  this  mode  of 
interpretation  ;  but  another  one  is  required  for  extra-uterine  preg- 
nancy. Where  the  ovum  is  developed  in  the  tube,  or  in  the  abdo- 
men, or  substance  of  the  womb,  what  in  fact  becomes  of  this 
balance  betwixt  the  action  of  the  fibres  of  the  neck  and  body,  this 
magazine  held  in  reserve,  this  unfolding  of  the  fibres,  which  at  a 
first  view  gives  so  satisfactory  a  solution  of  all  the  other  cases  ? 
Let  us  then  frankly  confess  that  the  deeper  we  search  into  the  ques- 
tion of  the  determining  causes  of  labour,  the  greater  will  be  the 
number  of  objections  against  the  explanations  that  have  been  given  ; 
but  do  we  any  better  know  the  determining  causes  of  the  contrac- 
tion of  the  heart,  and  of  an  infinity  of  other  actions  which  like  it  must 
be  admitted  as  facts  ? 


SECTION  2. 
Of  Labour. 

674.  The  name  labour  or  travail  is  given  to  the  collection  of 
phenomena  which  constitute  child-birth  ;  or,  if  we  choose,  child-birth 
gives  rise  to  a  series  of  phenomena,  local  or  general,  which  are 
embraced  under  the  one  title  of  labour. 

675.  As  the  phenomena  of  labour  are  numerous,  and  appear  in 
succession,  it  has  been  frequently  attempted  to  group  them,  to  form 
different  bundles  of  tiiem,  so  as  to  class  them  better  in  the  memory  ; 
but  as  these  divisions  have  never  been  established  otherwise  than 
upon  arbitrary  or  purely  conventional  data,  it  has  happened  that 
they  do  not  resemble  each  other  in  any  two  books.     A.  Petit,  for 


OF  LABOUR.  263 

example,  admits  three,  without  saying  any  thing  of  the  Hmits  to  be 
allowed  to  each  of  them.  Stein  describes  four,  and  that  too,  not 
less  vaguely  than  the  former.  Millot  also  thinks  that  labour  ought 
to  be  divided  into  four  stages  :  the  first,  which  he  calls  the  secret 
stage^  because  the  women  are  scarcely  conscious  of  it,  comprises 
the  different  symptoms  that  manifest  themselves  in  the  four,  five  or 
six  days  immediately  antecedent  to  the  term  of  gestation  ;  the  second 
extends  from  the  first  appearance  of  the  pains  to  the  discharge  of 
the  waters  ;  the  third  begins  after  the  rupture  of  the  membranes  ; 
and  the  fourth  when  the  child  is  on  the  point  of  being  delivered. 

676.  Millot's  secret  stage  is  classed  among  the  precursory  signs 
by  Madame  Boivin,  who,  like  Chaussier  and  Adelon,  admits  five 
stages  ;  four  for  the  labour  itself,  and  the  fifth  for  the  delivery  of  the 
after-birth,  but  without  indicating  any  very  well  marked  line  of  dis- 
tinction between  them.  M.  Maygrier  also  reckons  four  stages,  as 
Stein  does,  and  does  not  circumscribe  them  either.  Denman  seems 
to  have  been  the  first  to  lay  the  foundation  of  a  good  division  of 
labour :  according  to  him  the  first  stage  commences  with  the  first 
pains,  and  ends  with  the  complete  dilatation  of  the  neck,  or  with 
the  rupture  of  the  membranes  ;  the  second  extends  to  the  complete 
expulsion  of  the  foetus ;  and  the  third  comprises  the  delivery  of  the 
after-birth.  In  this  way,  each  stage  forming  a  period  rigorously 
determined,  it  becomes  no  longer  possible  to  extend  or  limit  as  we 
please,  the  acceptation  of  the  terms  made  use  of.  We  might  also, 
after  the  example  of  Burns,  describe  only  two  stages,  properly  so 
called,  and  make  the  delivery  of  the  secundines  a  separate  labour, 
which  appears  to  me  to  be  rational.  M.  Desormeaux,  who  was 
fully  sensible  of  the  advantages  of  Denman's  method,  has  done  better 
by  carrying  the  first  stage  to  the  complete  dilatation  of  the  os  uteri, 
without  regard  to  the  rupture  of  the  membranes.  I  shall  adopt  this 
course  myself,  and  divide  labour  only  into  two  principal  stages  :  one 
which  terminates  when  the  dilatation  is  finished,  and  another  which 
begins  at  that  moment,  and  ends  with  the  delivery  of  the  child. 

Nevertheless,  I  shall  add,  as  an  independent  period,  what  Millot 
calls  the  secret  stage,  or  what  Madame  Boivin  describes  under  the 
title  o( precursory  signs. 

§.  I.  Precursory  signs,  or  preliminary  symptoms  of  labour. 

677.  Labour  sometimes  comes  on  suddenly,  and  without  any 
preliminary  symptom ;  however,  the  organism,  which  rarely  pro- 
ceeds to  the  exercise  of  its  smallest  functions  without  some  pre- 
lude, is  most  commonly  true  to  its  accustomed  march,  whenever  the 
question  is  upon  terminating  the  great  act  of  reproduction. 


264  PRECURSORY  SIGNS. 

From  two  to  fifteen,  and  even  twenty  days  before  the  period,  na- 
ture in  some  subjects  seems  to  try  her  forces  ;   the  belly  diminishes 
in  size  sensibly ;  the  fundus,  and  even  the  whole  mass  of  the  womb, 
subsides  ;  the  motions  of  the  child  are  felt  more  than  in  common  ; 
the  infiltration  and  the  varicose  condition  of  the  lower  extremities 
increase  or  now  become  manifest,  if  not  previously  present ;  the 
labia  pudendi  in  particular  become  swelled,  softened,  and  occasion- 
ally painful ;  the  digestion  is  better  performed  ;  the  nausea,  vomit- 
ings, and  curious  appetite  are  done  away  with,  if  they  had  not  long 
before  ceased  to  exist ;   the  respiration  is  not  so  short,  nor  so  im- 
peded ;  the  women  regain  their  habitual  gaiety  and  lively  humour, 
are  not  so  sleepy,  more  disposed  to  exertion,  more  active,  and  often 
induced  to  believe,  at  least  in  first  pregnancies,  that  their  term  is 
further  off  than  they  had  before  supposed.     They  have  a  sense  of 
weight  in  the  pelvis,  or,  as  they  say,  at  the  fundament,  with  more 
frequent  disposition  to  stool,  and  to  void  their  urine.    It  is  then,  par- 
ticularly, that  all  the  articulations,  all  the  ligaments  of  the  pelvic 
cavity  become  softened  and  relaxed  ;  which  renders  walking,  and 
-  even  standing  itself  more  difl5cult,  more  fatiguing,  and  sometimes 
even  absolutely  painful,  although  the  woman  is  more  disposed  for 
them.     The  secretion  of  mucus  in  the  genital  passages  becomes' 
more  active,  and  glairy  matter  in  more  or  less  abundance  escapes  in 
flocks  from  the  vagina  and  vulva ;  it  is  not  very  rare  to  find  the 
womb  in  an  altogether  peculiar  state  of  fibrillar  contraction,  which 
may  be  regarded  as  a  passage  from  its  state  of  rest  to  that  of  its 
real  contraction  :  that  is  to  say,  by  touching  the  os  uteri,  we  feel 
that  it  is  from  time  to  time  in  a  state  of  slight  tension  or  constric- 
tion, and  by  feeling  of  the  body  of  the  organ  above  the  pubis,  a 
movement  is  found  to  take  place  in  it;  so  true  is  it,  that  the  point 
of  departure  of  labour  cannot  always  be  precisely  determined. 

678.  These  different  phenomena,  which  necessarily  vary  in  num- 
ber, progress  and  degree  in  different  women,  are  in  general  of  good 
augury,  provided  they  are  not  converted  into  symptoms  of  disease. 
They  announce  that  nature  is  collecting  her  forces,  uniting  her  re- 
sources, and  making  all  suitable  dispositions  to  accomplish  the  func- 
tion she  has  been  so  long  preparing  for.  As  to  their  explanation,  it 
is  perfectly  natural ;  they  all  refer  directly  or  indirectly  to  the  change 
of  position  of  the  womb.  By  plunging  down  into  the  excavation, 
this  organ  necessarily  presses  with  more  or  less  force  upon  the  reo- 
tum,  the  bladder,  the  nervous  plexuses  and  the  blood  vessels ;  thence 
come  the  tencsnms,  the  bearing  down,  the  lymphatic  or  sanguine 
engorgement  of  the  lower  limbs  and  vulva,  the  relaxation  of  the 


PRECURSORY  SIGNS.  265 

symphyses,  the  formation  of  mucus,  &c.  By  sinking  lower  down, 
and  removing  to  a  distance  from  the  epigastrium,  the  womb  leaves 
the  stomach  and  liver  more  unconstrained  ;  the  diaphragm,  being 
less  elevated,  permits  the  lungs  to  dilate  more,  whence  more  freedom 
in  respiration,  circulation,  the  digestive  functions,  and  consequently 
in  the  exercise  of  the  intellectual  and  locomotive  faculties. 

§.  II.  First  stage,  or  period  of  dilatation. 

679.  After  these  preliminaries,  labour  at  length  begins;  its  origin 
is  marked  by  pains,  and  short  and  sHght  colicky  sensations,  recur- 
ring at  considerable  intervals.  The  external  parts  of  generation 
become  moist,  and  the  secretion  of  glairy  mucus,  provided  it  had 
not  appeared  before,  is  added  to  the  number  of  precursory  symp- 
toms. When  the  colic  pains  are  present,  the  womb  hardens,  be- 
comes rounder,  and  its  summit  sinks  into  the  excavation,  it  dimin- 
ishes in  all  its  diameters,  in  one  word,  it  contracts ;  the  lips  of  the 
OS  tincae  are  effaced,  and  in  an  evident  manner  grow  thinner ;  the 
orifice  stretches,  and  from  the  same  cause  loses  its  thickness,  assumes 
more  decidedly  the  form  of  a  circle,  and  manifestly  contracts ;  by 
introducing  the  finger  into  it,  the  membranes  of  the  ovum  will  be 
found  endeavouring  to  engage  in  it,  they  are  compressed  by  it  and 
forced  lower  down,  they  grow  harder,  become  tense,  very  elastic, 
and  difficult  to  indent.  The  woman  is  now  frequently  torment- 
ed with  sinister  forebodings  ;  she  becomes  low  spirited,  and  despairs 
of  safety,  says  she  is  going  to  die,  loses  all  her  courage,  and  is  over- 
whelmed with  gloomy  thoughts,  and  a  sadness  which  nothing  seems 
able  to  dispel ;  she  weeps,  is  agitated,  or  remains  motionless,  and  in 
some  instances  feels  horripilations  all  over  the  body.  Animals 
themselves,  a  very  remarkable  circumstance,  also  fall  into  this  state 
of  lowness  at  the  commencement  of  labour  ;  they  refuse  to  eat  or 
drink,  seem  to  be  tormented  with  fear,  and  to  be  occupied  only  with 
the  dangers  that  threaten  them. 

680.  The  pains,  which  gradually  increase  in  strength  and  severity, 
at  the  same  time  become  longer  and  more  frequent ;  reddish  or 
bloody  striae  are  soon  found  to  be  mixed  with  the  mucous  discharges, 
which  are  also  found  to  be  increased  in  quantity  ;  the  mouth  of  the 
womb  begins  to  open,  and  dilates  by  degrees ;  the  lower  segment  of 
the  ovum  passes  through  it,  and  under  the  title  of  bag  of  waters, 
projects  into  the  upper  part  of  the  vagina ;  as  the  pains  grow  more 
severe,  the  general  irritation  becomes  more  considerable  ;  the  inter- 
val between  the  contractions  is  not  calm  ;  the  woman  is  touchy,  cross, 
impatient,  difficult  to  control ;  she  cannot  keep  in  one  place,  is  dis- 
contented with  every  body,  and  has  an  extreme  susceptibility  ;  every 

21 


266  STAGES  OF  LABOUR. 

pain  in  some  degree  resembles  a  paroxySm  of  fever  ;  it  is  preceded 
with  a  rigor  and  sometimes  even  with  a  tremor  and  rattling  of  the 
teeth  together ;  the  quickness,  frequency  and  hardness  of  the  pulse 
and  temperature  of  the  body  augment ;  the  skin  is  higher  coloured 
and  becomes  moist ;  the  mouth  and  tongue  dry  ;  the  teeth  and  lips 
are  encrusted,  become  fuliginous,  as  in  an  adynamic  fever  ;  a  great 
thirst  comes  on  ;  she  has  nausea,  vomiting  and  cough  ;  she  wanders, 
and  the  intellectual  derangement  is  often  carried  to  such  an  extent 
as  to  resemble  delirium.  In  irritable  women,  the  anguish  and  rest- 
lessness are  sometimes  carried  to  the  highest  degree  ;  and  the  hardest 
heart  could  scarcely  resist  a  feeling  of  compassion  and  pity  at  the 
sight  of  these  unhappy  beings,  who  with  dishevelled  hair,  blackened 
mouths,  flushed  countenances,  burning  skin  and  haggard  eyes,  can 
only  become  mothers  at  the  cost  of  so  many  sufferings  and  dangers. 
When  a  contraction  is  over,  every  thing  returns  to  its  natural  state  ; 
the  restlessness  ceases  ;  the  pulse  recovers  its  ordinary  type ;  the 
mouth  becomes  moist ;  the  skin  regains  its  natural  colour  and  habi- 
tual temperature  ;  if  an  examination  be  now  made,  the  membranes, 
having  returned  within  the  cavity  of  the  womb,  feel  flaccid  and 
wrinkled,  and  the  bag  of  waters  cannot  be  felt ;  the  edges  of  the  os 
uteri,  which  during  the  pain  were  hard,  thin  and  sharp,  are  supple, 
thick,  and  rounded  immediately  after  it.  The  nausea  is  suspended, 
but  the  belly,  particularly  the  epigastrium,  most  generally  remains 
very  tender.  Each  pain  reproduces  the  same  series  of  phenomena, 
and  is  succeeded  by  a  more  and  more  complete  remission,  which  also 
grows  shorter  and  shorter.  The  os  uteri,  which  represeats  the  re- 
sistance to  be  overcome,  gradually  yields  ;  its  dilatation  at  length 
becomes  so  complete,  as  that  there  is  no  contraction  betwixt  the 
uterus  and  vagina.  Thus  is  terminated  the  first  stage  of  labour,  the 
longest  and  most  fatiguing  period  of  parturition,  but  not  the  most 
dangerous  or  difficult. 

,  <J^§.  in.  Second  stage,  or  period  of  expulsion. 

681.  In  the  first  stage  the  womb  performs  almost  the  whole  duty 
of  the  labour  ;  it  dilates  the  cervix,  and  forces  the  apex  of  the  ovum 
to  engage  itself  therein  ;  it  cither  does  not  solicit  at  all,  or  but  very 
feebly,  the  contractions  of  the  muscles,  whose  concurrence  has  not 
as  yet  become  indispensable.  In  the  second  stage,  the  contractions 
in  the  first  place  becoipe  stronger,  last  for  a  longer  period  of  time, 
are  not  so  far  apart,  and  yet  are  followed  by  a  more  decided  calm  ; 
the  courage  returns,  the  sadness  is  dissipated  ;  some  women,  op- 
pressed with  the  want  of  rest,  sleep  quite  soundly  during  the  short 
interval  between  the  pains  ;  I  once  attended  a  lady  in  labour,  who 


*  '  STAGES  OF  LABOUR.  267 

having  been  three  days  and  nights  in  the  anguish  of  a  most  painful 
travail,  slept  several  times  on  the  morning  of  the  fourth,  notwith- 
standing that  the  contractions  were  carried  to  the  highest  degree  of 
intensity,  and  there  was  scarcely  more  than  one  or  two  minutes  be- 
tween them.  A  feeling  of  weight  and  bearing  down,  by  some  re- 
ferred to  the  pressure  experienced  by  the  cervix,  but  which  depends 
rather  upon  that  of  the  rectum  and  bladder,  soon  compels  the  woman 
to  second  her  pains  ;  and  almost  in  spite  of  herself,  to  contract  the 
abdominal  muscles  and  make  the  most  violent  efforts. 

682.  The  bag  of  waters,  the  only  portion  of  the  ovum  which  is 
not  compressed  externally,  having  no  support  whatever  in  the  supe- 
rior part  of  the  vagina,  bursts  in  the  midst  of  one  of  the  most  vio- 
lent pains  ;  the  foetus,  forced  downwards  by  the  same  contraction, 
immediately  takes  the  place  occupied  by  the  segment  of  the  mem- 
branes, and  by  engaging  in  the  passage  like  a  stopper  or  plug,  pre- 
vents tlie  escape  of  the  rest  of  the  waters ;  and  the  head,  if  it  be  the 
presenting  part,  is  then  said  to  be  at  the  crowniifg  (couronnemenf);  the 
void  thus  produced  in  the  womb  is  the  reason  why  the  labour  seems 
to  slacken  for  a  little  while  ;  but  when  this  void  disappears,  and  the 
uterus  is  recovered  from  its  astonishment^  (I  hope  the  expression  will 
be  pardoned,)  the  pains  recover  all  their  energy,  and  succeed  each 
other  with  greater  rapidity.  Each  one  is  ushered  in  with  a  general 
shiver ;  the  severest  ones  are  often  preceded  by  another  which  is 
milder,  and  serves  as  a  prelude  to  it ;  on  other  occasions  we  observe 
one  stronger  and  one  weaker,  alternately,  regularly,  and  without 
our  being  able  to  regard  one  as  a  sequel  to  the  other.  When  they 
come  on,  the  woman  lays  hold  of  any  thing  solid  in  her  reach,  plants 
her  heels  upon  the  mattrass,  seizes  with  her  hands  the  sides  of  the 
bed  or  bolster,  or  the  persons  around  her,  to  secure  a  point  d'appui ; 
she  then  throws  her  head  back,  draws  a  long  breath,  and  all  the  levers 
of  her  skeleton  being  thus  fixed,  contracts,  with  all  her  power,  the 
muscles  of  the  belly,  while  the  diaphragm,  and  all  the  muscles  of  her 
body  act  with  the  same  energy  ;  the  neck  and  face  swell,  are  engorged 
with  blood,  and  become  purple  or  livid  ;  the  jugular  veins  acquire 
an  enormous  size  ;  the  carotids  beat  violently  ;  the  thyroid  gland 
becomes  engorged,  the  eyes  sparkle,  grow  red,  and  seem  to  start 
from  their  orbits  ;  all  the  symptoms  of  cerebral  congestion  become 
manifest ;  the  general  circulation  is  strongly  excited  ;  sweat  some- 
times pours  from  the  skin,  but  only  about  the  head,  breast  and  ab- 
domen, for  the  lower  extremities,  receiving  less  blood  than  common, 
not  unfrequently  remain  below  their  ordinary  temperature;  at  length, 
when  the  contraction  is  just  about  to  cease,  this  agitation  gives 
place  to  rapid  sobs,  which  soon  restore  calmness  to  the  functions. 


268  STAGES  OF  LABOUR. 

683.  After  a  certain  length  of  time,  generally  very  short,  another 
pain  comes  on,  accompanied  with  the  same  anguish,  and  followed  by 
the  same  phenomena.  As  it  begins,  a  small  quantity  of  liquor 
amnii  is  seen  to  flow  off,  because  the  child  does  not  exactly  fill  up 
the  cervix  during  the  interval  between  the  pains  :  but  by  forcing  the 
presenting  part  to  engage  in  the  utero-vaginal  orifice,  the  uterine 
contraction  soon  puts  a  stop  to  this  discharge,  which  reappears 
towards  the  close  of  each  pain,  because  the  foetus,  ceasing  to  be 
pressed  downwards,  returns  into  the  cavity  of  the  womb.  If  the 
pains  be  somewhat  strong,  the  head  soon  passes  through  the  cervix 
into  the  upper  part  of  the  vagina,  which  gradually  dilates  to  receive  it, 
and  it  descends  into  the  excavation,  exerting  an  increasing  pressure 
on  the  rectum  and  bas-fond  of  the  bladder ;  the  bearings  down  are  novjr 
redoubled,  strangury  comes  on,  and  cramps  are  felt  in  the  thighs  and 
legs  ;  if  any  faecal  matters  are  contained  in  the  rectum  below  the  su- 
perior strait,  they  are  mechanically  forced  out ;  the  amplitude  of 
the  vagina  increases*  in  every  direction  by  the  unfolding  of  the 
wrinkles,  always,  except  during  labour,  observable  on  its  interior. 
The  head  approaches  the  inferior  strait,  the  coccyx  retires  back- 
wards, the  anus  projects  ;  the  whole  perineum  is  elongated,  and  be- 
comes thinner  as  the  inferior  angle  of  the  vulva  is  carried  forwards, 
and  the  plane  of  this  opening  at  last  comes  to  be  almost  parallel  with 
the  axis  of  the  body,  instead  of  representing,  as  before,  the  plane  of 
the  lesser  strait  of  the  dried  pelvis ;  the  labise  being  put  on  the 
stretch  are  undoubled,  and  even  drag  a  portion  of  the  skin  of  the 
thighs  towards  themselves :  the  mens  veneris  is  lessened  in  size  ; 
but  it  is  false,  entirely  false,  to  say  that  the  nymphas  are  also  unfold- 
ed :  at  length  a  pain,  which  is  stronger  than  any  preceding  one, 
which  forces  the  woman  to  utter  cries  of  despair,  and  which  is  com- 
posed of  two  pains  of  unequal  violence,  for  which  nature  seems  to 
have  rallied  all  her  remaining  muscular  power,  triumphs  over  all  re- 
sistance ;  the  most  powerful  contraction  that  has  yet  occurred  brings 
the  parietal  protuberances  on  a  level  with  the  tuberosities  of  the 
ischia ;  one  more  last  degree  of  power  is  about  to  force  them 
through,  but  that  power  is  just  about  to  diminish  ;  nature,  who  has 
almost  overcome  all  obstacles,  seems  to  be  ready  to  fail  in  her  last 
effort ;  just  as  she  is  about  to  attain  the  object  of  so  many  exertions, 
she  is  seen  ready  to  yield  once  more  to  the  reactions  of  the  peri- 
neum ;  but  one  more  attempt  of  the  organism  gives  rise  to  a  new 
pain,  which  comes  to  the  assistance  of  the  preceding  one  before  it 
has  quite  ceased,  as  if  to  sustain  it,  and  the  head  finally  escapes 
through  the  vulva.  In  consequence  of  the  vacuity  which  has  just 
occurred  in  the  womb,  provided  the  body  of  the  child  does  not  im- 


STAGES  OF  LABOUR.  269 

mediately  follow  the  head,  it  is  not  commonly  expelled  until  after  a 
calm  of  a  few  seconds  or  a  few  minutes,  when  a  short  and  moder- 
ately strong  contraction  occasions  its  escape,  together  with  that  of 
the  remainder  of  the  liquor  amnii. 

684.  The  labour  is  finished.  One  of  the  most  melting  scenes,  a 
scene  most  adapted  vividly  to  affect  the  human  heart,  is  presented  to 
the  eyes  of  the  philosophical  accoucheur.  To  those  piercing  cries 
and  violent  agitation,  to  those  transports  of  despair,  those  excessive 
efforts,  those  inexpressible  agonies,  those  dilacerating  pains,  which 
seem  to  be  intolerable,  instantly  succeeds  a  delicious  calm,  full  of 
charms,  says  M.  Desormeaux,  and  interrupted  only  by  the  happy 
idea  of  being  a  mother.  The  new  born  child  cries,  and  all  the  suf- 
ferings of  the  mother  so  courageously  borne  are  forgotten  ;  pas- 
sionate expressions  of  satisfaction  are  substituted  for  those  of  pain, 
sobs  of  happiness  succeed  to  the  sobs  of  despair  ;  and  this  sudden 
transition  from  the  extremest  dread,  from  a  frightful  state  of  anxiety, 
to  the  height  of  joy  and  of  the  tenderest  affections,  is,  in  sensible  and 
amiable  women,  one  among  those  appearances  which  most  imperi- 
ously demand  our  admiration  for  a  sex  whose  other  claims  to  it  are 
BO  numerous ! 

685.  Duration  of  labour.  There  is  no  occasion  for  me  to  remark 
that  this  general  picture  is  far  from  being  applicable  to  all  women, 
or  even  to  all  the  labours  of  the  same  woman  ;  most  of  these  nu- 
merous phenomena  are  to  be  met  with,  chiefly  among  those  who 
are  robust,  vigorous,  young,  and  in  labour  for  the  first  time  :  in 
others,  they  exhibit  very  varied  appearances.  Their  development 
requires  a  lapse  of  time  which  also  presents  very  great  variety  in 
different  countries  and  in  different  women. 

The  duration  of  labour  is,  according  to  the  reports  of  travellers, 
much  shorter  among  savages  than  among  civilized  people  ;  among 
the  Negroes  and  Indians  of  America  than  among  Asiatics  and 
Europeans  ;  in  hot  climates  than  in  cold  countries ;  in  Italy,  Spain, 
and  Portugal,  for  example,  than  in  France,  Russia,  and  Germany  ; 
in  women  who  have  passed  their  lives  in  luxury  and  idleness,  than  in 
those  who  live  in  the  country,  and  are  obliged  to  labour  hard  for  a 
support.  In  general,  labour  lasts  from  four  to  eight  or  ten  hours 
in  Holland,  England  and  France  :  it  is  about  the  same  in  Switzer- 
land and  Germany  ;  so  that  Haller  was  evidently  deceived  when  he 
stated  that  the  duration  of  a  labour  is  from  an  hour  and  a  half  to 
two  hours.  The  mean  term  of  this  function,  therefore,  as  is  re- 
marked by  M.  Desormeaux,  is  about  four  hours. 

The  four  most  constant  and  essential  phenomena  of  labour  are, 
as  may  have  been  above  seen,  the  contraction  of  the  uterus,  or 


270  STAGES  OF  LABOUR. 

pain.)  the  dilatation  of  the  cervix,  the  formation  of  the  bag  of  waters, 
and  the  discharge  of  glairy  mucus. 

§.  IV.  Of  Labour-pains. 

686.  In  midwifery,  the  word  pain  is  synonymous  with  uterine 
contraction ;  nevertheless,  it  should  not  be  forgot  that  this  is  only 
conventional  language,  employed  by  physicians  to  make  themselves 
understood  by  the  vulgar,  and  that  these  two  things  are  essentially 
distinct.  It  is  true  that  pain  is  connected  with  contraction  of  the 
womb  ;  that  they  begin,  progress,  decrease,  and  cease  together  ; 
that  the  energy  of  the  one  is  most  commonly  in  a  direct  ratio  to  the 
acuteness  of  the  other  ;  but  it  is  very  certain,  also,  that  the  contrary 
may  be  met  with,  so  that  no  labour  can  be  concluded  without  the 
contraction,  while  many  may  be  cited  as  having  taken  place  without 
pain.  Every  body  has  observed,  like  M.  Flamant,  that  in  most  wo- 
men the  contractions  come  on  a  good  while  before  the  pains. 
Nevertheless,  it  is  by  the  pain  that  we  estimate  the  contraction  and 
its  strength  ;  the  former  is  the  sign  of  the  latter.  However,  there 
may  be  numerous  shades  of  difference  in  the  intensity  of  the  pains, 
without  the  strength  of  the  contraction  being  on  that  account 
necessarily  different.  In  a  nervous  and  extremely  irritable  woman 
a  very  slight  contraction  sometimes  produces  the  very  severest  pain ; 
on  the  contrary,  a  woman  of  a  lymphatic  temperament,  indifferent 
as  to  small  matters,  and  who  has  but  little  sensibility,  scarcely  suf- 
fers at  all,  although  the  womb  contracts  powerfully  ;  some  women, 
from  an  excess  of  timidity,  fear,  or  pusillanimity,  cry  out  aloud  upon 
the  slightest  contraction  of  the  womb,  while  courage  and  resigna- 
tion lead  others  to  bear  the  stongest  contractions  without  complain- 
ing. Finally,  there  are  a  few  who,  for  the  purpose  of  securing  more 
attention  or  inspiring  more  compassion  and  pity,  scream  and  worry 
themselves  in  a  most  extraordinary  manner,  although  they,  in  re- 
ality, suffer  but  very  little.  There  are  also  those  who  arm  themselves 
with  artificial  courage,  who  resolve  beforehand  not  to  complain  nor 
cry  out,  no  matter  how  strong  the  pains  may  be,  and  at  the  ex- 
pense of  life  make  the  most  incredible  efforts  to  impose  silence 
upon  the  most  violent  sufferings,  and  refrain  from  the  most  legitimate 
outcries  ;  so  true  it  is  that  charlatanism  and  ostentation  find  occa- 
sions for  exercise  even  in  human  infirmities  !  It  may  also  happen 
that  the  presence  of  strangers,  or  of  persons  displeasing  to  the  wo- 
man in  labour,  of  whom  she  is  afraid,  or  with  whom  she  naturally 
has  no  familiarity,  restrain  her  and  prevent  her  from  giving  free  ex- 
pression to  the  sensations  she  experiences. 

687.  At  the  commencement,  the  pains  are  so  weak  and  super- 


LABOUR-PAINS.  371 

ficial,  that  they  have  received  the  title  of  flies  (mouches),  doubtless 
in  allusion  to  the  slight  sensation  produced  by  the  bite  of  that  insect, 
or  that  occasioned  by  its  creeping  on  the  skin.  They  are  then 
called,  also,  preliminary  pains,  little  pains  :  characterised  by  a  sort 
of  shuddering  of  the  body  of  the  womb,  they  arise  in  the  umbilical 
region,  and  are  lost  therein,  or  spread,  so  to  speak,  over  the  whole 
hypogastrium  and  flanks.  At  a  more  advanced  stage,  when  the 
labour  is  fairly  set  in,  the  pains,  which  are  longer,  stronger,  nearer 
together,  and  more  decided,  are  called  preparative;  never  was 
epithet  better  applied  ;  their  business  is,  in  fact,  to  prepare  for  the 
expulsion  of  the  ovum,  or  preside  over  the  dilatation  of  the  cervix  ; 
from  the  neighbourhood  of  the  umbilicus  they  generally  extend  to- 
wards the  sacro-vertebral  angle,  or  to  the  centre  of  the  strait ;  this 
is  the  period  during  which  the  woman  is  most  impatient,  cross,  sad, 
worried,  difficult  to  govern,  and  utters  the  sharpest  cry,  which  per- 
haps depends  upon  the  woriib  acting  alone,  and  leaving  to  the  wo- 
man the  free  exercise  of  her  general  sensibility. 

At  the  end  of  the  first  stage,  and  more  particularly  in  the  second, 
the  pains  visibly  change  their  character,  assume  the  denomination 
of  bearing  or  expulsive  pains,  and  in  fact  announce  that  nature  is 
employing  all  her  resources  for  the  expulsion  of  the  foetus.  These 
pains,  which  are  also  designated  as  the  great  pains,  are  much 
stronger,  longer,  and  more  complete  than  those  of  the  first  stage, 
and  are,  besides,  characterised  by  being  separated  by  intervals  more 
perfect,  better  marked,  and  more  calm,  by  giving  rise  to  strangury  and 
tenesmus,  or  a  sense  of  weight  which  brings  the  abdominal  muscles 
into  play,  force  the  woman  to  bear  down,  and  make  exertions  to  assist 
the  uterus.  Notwithstanding  their  severity,  they  do  not  excite  her 
irritability  so  much,  and  are  borne  with  more  resignation  and  patience. 
The  women  who  seem  carefully  to  avoid  every  preparative  pain,  are, 
on  the  contrary,  anxious  for  the  return  of  the  expulsive  ones  ;  they  in- 
vite and  solicit  them  ;  they  converse,  are  tranquil,  and  during  the  in- 
tervals between  them,  are  even  lively,  and  forget  the  dangers,  a  sense 
of  which  had  previously  caused  them  to  be  so  downcast.  Their  cries 
are  different  from  those  they  uttered  in  the  first  or  second  stages. 
The  cries  which  accompany  the  first  are  sharp,  and  resemble  those 
occasioned  by  any  other  species  of  suffering.  Those  of  the  second 
stage,  on  the  contrary,  seem  to  be  suppressed  like  those  of  a  person 
carrying  a  heavy  burthen.  The  former  are  free  and  open,  and  take 
place  during  the  act  of  expiration ;  the  latter  are  restrained  by  the 
closure  of  the  glottis,  and  can  scarcely  be  heard  except  during  inspi- 
ration ;  the  former  are  expressive  of  suffering,  the  latter  of  exertion. 

688.  When  the  labour  approaches  its   termination,  the  pains. 


273  LABOUR-PAINS. 

which  are  sometimes  of  an  extreme  degree  of  violence,  are  pretty 
frequently  accompanied  with  a  kind  of  convulsive  trembling,  during 
which  it  seems  as  if  the  bones  of  the  pelvis  are  about  to  separate  or 
break,  and  all  the  genital  organs  threatened  with  immediate  lacera- 
tion, have  been  denominated  dolores  conquassantes^  a  barbarous  and 
ill-sounding  term,  but  strongly  expressive  of  the  state  of  the  case  ; 
their  only  special  character,  however,  is  their  high  degree  of  inten- 
sity, for  they  do  not  otherwise  differ  from  the  expulsive  pains,  pro- 
perly so  called. 

689.  As  has  been  already  seen,  the  direction  of  the  pains  is  not 
the  same  in  every  stage  of  the  labour ;  they  most  frequently  follow 
the  great  axis  of  the  womb,  or  the  occipito-coccygeal  diameter  of 
the  foetus,  and  consequently  terminate  at  a  point  which  is  so  much 
the  nearer  to  the  centre  of  the  vulva,  in  proportion  as  the  foetus  is 
nearer  its  passage  through  the  inferior  strait ;  whence  it  follows  that 
an  anterior  obliquity  of  the  womb  is  one  of  the  most  evident  causes 
of  those  disagreeable  pains  that  are  called  pains  in  the  back,  and  to 
the  consideration  of  which  I  shall  return  in  another  page. 

Causes.  The  pains  of  labour  are  occasioned  by  the  contractions 
of  the  uterus  :  but  what  is  the  nature  of  their  mechanism  ?  At  the 
time  of  labour  the  womb  is  a  muscle  ;  but,  in  the  natural  order  of 
things,  muscular  contractions  are  not  at  all  painful.  The  heart,  the 
diaphragm,  the  stomach,  the  intestines,  the  rectum,  and  the  bladder 
give  rise  to  no  pain  by  their  contractions.  The  most  violent  con- 
tractions, even,  of  the  muscles  of  the  abdomen,  in  labour,  are  not 
painful ;  we  cannot  therefore  look  to  the  fleshy  structure  of  the 
womb  for  the  cause  of  the  pain.  Stein  says  that  women  would 
doubtless  bring  forth  their  children  without  any  pain,  were  it  not 
for  the  powerful  resistance  offered  to  the  passage  of  the  foetus  by 
the  inferior  segment  of  the  womb  and  the  neighbouring  parts,  which 
by  their  antagonism  give  rise  to  pain.  According  to  Levret,  Asdru- 
baU,  ^c.  there  is  not  the  least  doubt  that  the  seat  of  labour  pain  is 
in  the  very  orifice,  non  vi  cade  questione  alcuna  che  in  esso  onficio 
i  il  luogo  positivo  ove  si  articolano  i  dolori  del  parto,  &c.  and  not 
in  tlie  body  and  fundus  of  the  uterus,  as  supposed  by  most  accouch- 
eurs. Denman,  in  speaking  of  labour-pain,  does  not  attempt  to  de- 
fine their  seat ;  he  is  satisfied  with  stating  that,  in  labour,  the  de- 
gree of  power  can  only  be  estimated  by  the  resistance,  the  resist- 
ance by  the  pain,  and  the  pain  by  the  expression.  So  that  his 
opinion,  which  is  adopted  by  most  of  the  English  practitioners,  and 
which  Hopkins  characterises  as  the  most  rational  one,  is  very  nearly 
the  same  as  that  of  Stein  and  Levret. 

Hay  and  M.  Bilon  have  endeavoured  to  prove  that  the  seat  of 


LABOUR-PAINS.  273 

labour-pain  is  in  the  cervix  much  more  than  in  the  body  of  the 
womb ;  their  principal  argument  is,  that  the  former  receives  its 
nerves  from  the  sacral  plexus,  wliich  is  one  of  the  divisions  of  the 
cerebral  nervous  system,  while  the  latter  receives  its  supply  from  the 
hypogastric  plexus,  which  belongs  to  the  ganglionic  system,  and 
which  has  no  communication  with  the  brain.  Madame  Boivin,  who 
speaks  from  what  she  has  experienced  in  her  own  person,  advocates 
the  same  idea,  and  thinks  that  the  contractions  of  the  body  and 
fundus  of  the  womb  are  not  more  painful  than  those  of  the  abdo- 
minal muscles  and  bladder. 

690.  If  it  be  true  that  the  cervix  is  endowed  with  a  more  acute  sen- 
sibility, receives  a  more  abundant  supply  of  nerves  than  the  rest  of 
the  organ,  and  is  powerfully  stretched  by  the  contractions,  and  that 
all  the  efforts  of  the  uterus  are  directed  upon  that  point,  it  is  not 
less  so,  that,  during  the  strongest  as  well  as  the  weakest  contractions, 
the  pains  are  equally  felt  throughout  the  whole  extent  of  the  womb. 
If  the  pressure  of  the  foetus  and  the  tractions  exerted  upon  the 
cervix  were  the  only  causes  of  pain,  women  ought  not  to  suffer  at 
all  after  the  dilatation  is  completed  ;  yet,  notwithstanding,  their  most 
violent  sufferings  are  experienced  from  that  very  period  ;  and  dur- 
ing the  delivery  of  the  placenta,  is  it  in  the  neck  that  we  are  to 
place  the  seat  of  the  pains  ? 

691.  Others  have  asserted  that  the  pains  of  labour  are  owing  to 
the  compression  of  organs  contained  within  the  pelvis,  of  the  ner- 
vous plexuses,  for  example.  But  when  the  lumbar  or  sacral  nerves 
are  compressed,  pain  is  felt  in  the  limbs  and  not  in  the  excavation. 
The  pains  extend  from  above  downwards,  both  at  the  beginning  and 
end  of  the  process,  and  occupy  the  whole  hypogastrium,and  not  mere- 
ly the  lesser  basin  ;  as  long  as  the  head  remains  above  the  superior 
strait,  where  the  foetus  presents  transversely,  or  when  it  comes  by  the 
feet,  we  cannot  refer  the  pains  to  this  kind  of  compression.  To 
maintain,  with  some  writers,  that  they  depend  on  compression  of  the 
nervous  branches  distributed  upon  the  inner  surface  of  the  womb,  is 
only  to  advance  one  of  those  numerous  assertions,  hazarded  with- 
out proof,  which  are  but  too  often  met  with  in  medical  works. 

Thus  the  essential  cause  of  labour-pain  is  wholly  unknown  ;  it  is 
a  question  in  physiology  which  deserves  and  requires  new  re- 
searches. What  is  demonstrated  by  observation  is,  that  all  parts  of 
the  womb,  either  unitedly  or  singly,  may  be  the  seat  of  pain  during 
labour ;  that  in  certain  cases,  the  stretching  of  the  neck  concurs, 
perhaps,  more  than  all  other  causes  in  its  production,  and  that  pres- 
sure upon  the  neighbouring  parts  is  not  always  unconcerned  in  it. 

692.  There  is  another  long  debated  question  relative  to  the  in- 
2K 


274  LABOUR-PAINS. 

termittence  of  the  pains  of  labour.  A.  Petit  says,  that  were  not 
the  pain  to  cease  after  it  had  set  in,  or  if  there  were  only  one  single 
pain,  the  woman  would  sink  under  it,  and  could  not  bear  it ; 
whereas,  being  reduced  as  it  is  into  fragments,  the  sum  of  her  suf- 
ferings is  really  lessened  ;  in  other  words,  the  pains  of  parturition 
are  intermittent  because  they  are  not  continuous,  for  that  is  all  the 
explanation  given  by  A.  Petit.  A  physician  whom  Millot  opposes 
with  much  warmth  has  entered  more  deeply  into  the  question,  as- 
serting that  the  cause  of  the  intermittence  of  the  pains  is  found  in 
the  resistance  offered  by  the  ovum  to  the  contractions  of  the  womb. 
Others  have  since  endeavoured  to  explain  the  facts  as  follows  :  when 
the  womb  contracts  with  much  force,  say  they,  the  nerves  between 
its  different  strata,  or  even  on  its  inner  surface,  being  compressed  by 
the  external  surface  of  the  ovum,  soon  produce  a  degree  of  numb- 
ness in  them,  that  necessarily  puts  a  stop  to  the  contraction. 

But  the  pains,  in  these  cases,  ought  to  be  very  long  and  very  near 
to  each  other  at  the  commencement  of  the  labour,  instead  of  being 
so  fugacious  and  far  apart,  as  the  contractions  are  then  extremely 
feeble  ;  on  the  other  hand,  they  ought  at  the  close  to  be  shorter  and 
less  frequent,  inasmuch  as  the  compression  is  then  sudden  and 
most  violent ;  nor  are  the  pains  that  accompany  the  delivery  of  the 
secundines,  or  the  after-pains  that  follow  delivery,  and  which  still  pre- 
serve the  intermittent  type,  explained  in  a  manner  at  all  more  satis- 
factory, under  this  hypothesis. 

693.  Buffon  thought  that  the  cessation  of  each  pain  was  due  to 
the  detachment  of  the  placenta  ;  that  is  to  say,  according  to  this 
celebrated  man,  the  object  of  each  contraction  of  the  uterus  is 
to  detach  a  small  portion  of  the  after-birth,  and  as  soon  as  this  de- 
tachijtient  takes  place,  the  pain,  like  the  contraction,  must  cease  for 
a  moment.  Two  remarks  suffice  to  show  the  little  value  of  such  a 
supposition.  The  placenta  sometimes  comes  away  before  the 
foetus,  and  the  pains  are  not  on  that  account  less  intermittent  until 
the  labour  is  concluded.  In  other  cases  the  placenta  retains  its  ad- 
herence even  after  the  delivery  of  the  child,  which  does  not  change 
the  intermittent  character  of  the  pains. 

694.  In  stating  that  the  cause  exists  in  the  cessation  of  the  con- 
trtiction  of  the  muscular  fibre^  as  insisted  on  by  Millot,  who  thinks 
he  has  made  a  great  discovery,-  we  fall  back  again  to  the  petitio 
principii  for  which  A.  Petit  has  already  been  censured,  above  :  this 
is  to  displace  and  not  to  solve  the  problem. 

695.  During  the  contraction  the  blood  is  forced  back  into  the 
torrent  of  the  general  circulation,  says  Dr  Dewces  ;  the  womb 
grows  pale,  and  the  contraction  ceases  ;  a  new  affluxion  takes  place, 


LABOUR-PAINS.  875 

and  the  contraction  immediately  returns,  &c.  ;  but  this  explanation, 
which  in  fact  is  perfectly  similar  to  the  one  which  I  have  been  just 
now  opposing,  is  liable  to  the  same  objections,  and  not  at  all  more 
admissible. 

696.  In  conclusion,  we  do  not  know  the  cause  of  the  intermit- 
tence  of  the  uterine  contractions,  any  more  than  we  do  that  of  the  con- 
tractions of  the  heart,  the  intestines,  and  the  muscles  in  general, 
or  that  of  all  imaginable  intermittence,  whether  functional  or 
organic.  Inasmuch  as  we  cannot  grasp  a  body  strongly  in  the 
hand  without  being  soon  obhged  to  relax  it,  wherefore  should  it  be 
supposed  that  the  contraction  of  the  womb  does  not  require  to  be 
alternated  with  relaxation  ?  The  nature  of  the  phenomena  is  simi- 
lar in  each  of  the  cases  ;  its  cause  must  be  identical,  and  I  cannot 
perceive  why  we  should  with  so  much  ardour  seek  for  it  in  the  one, 
when  we  have,  in  some  measure,  agreed  to  abandon  it  in  the  other. 
It  is  a  question  which  will  doubtless  long  remain  unsolvable,  but 
which  belongs  much  more  to  general  physiology  than  to  tokology 
in  particular. 

§.  V.  Of  the  dilatation  of  the  os  uteri. 

697.  Pain  is  the  first  symptom  of  labour  ;  but  it  is  neither  the 
most  essential  nor  constant  one  ;  for,  as  has  been  pointed  out  by 
Levret,  Denman  and  Hopkins,  it  may  be  conceived,  that  there  may 
be  cases  in  which  it  is  possible  for  women  to  be  delivered  without 
any  pain,  whereas  it  is  materially  impossible  for  her  to  be  so  with- 
out the  dilatation  of  the  os  uteri.  This  process  of  dilatation,  which 
is  wholly  subordinate  to  the  power  of  the  uterine  contractions,  re- 
quires to  be  well  understood.  It  is  slow  and  not  very  perceptible 
at  the  commencement,  but  is  effected  with  great  rapidity  towards  the 
close  of  labour.  It  generally  requires  more  time  to  enlarge  it  to 
the  size  of  a  crown  piece,  than  to  complete  its  dilatation,  when  its 
diameter  is  about  three  inches.  The  orifice,  which  is  for  the  most 
part  very  thin  and  somewhat  sharp,  when  touched  at  the  beginning, 
especially  in  a  first  labour,  communicates  an  impression  like  that 
which  would  be  felt  upon  touching  a  ring  of  fine  cord  slightly 
stretched.  In  the  latter  half  of  the  first  stage  it  becomes,  on  the 
contrary,  thicker,  and  sometimes  forms  a  kind  of  roundish  cushion, 
which  seems  to  yield  before  the  child's  head,  but  gradually  disap- 
pears when  the  head  passes  or  engages  in  the  strait.  The  very  con- 
trary of  this  is  remarked  in  women  who  have  had  many  children  ; 
the  lips  of  the  os  uteri,  which  at  first  are  soft  and  supple,  still  some- 
times retain  a  thickness  of  several  lines,  even  although  the  labour 
may  be  somewhat  advanced  ;  it  is,  however,  only  at  a  later  period, 


276  LABOUR-PAINS. 

when  the  bag  of  waters  begins  to  form,  that  they  begin  gradually 
to  grow  thinner. 

698.  In  both  the  above  cases,  the  diminution  in  thickness  is  far  from 
taking  place  with  the  same  regularity  on  every  point  of  the  circum- 
ference of  the  circle.  I  have  often  seen  its  posterior  half  as  thin  as 
the  edge  of  a  sheet  of  paper,  while  its  anterior  semi-circumference 
formed  betwixt  the  head  and  pubis  a  cushion  from  three  to  four 
lines  in  thickness.  This  inequality,  which  is  in  some  sort  natural, 
and  almost  always  to  be  met  with  in  various  degrees,  ought  not  to 
be  overlooked,  whenever  we  attempt  to  determine  the  duration  of 
the  labour :  by  touching  the  anterior  half  of  the  cervix  without  car- 
rying the  finger  far  back,  one  might  be  led  to  prognosticate  a  pretty 
tedious  time,  while  another  person,  after  having  explored  the  opposite 
side,  would  announce  that  the  labour  is  just  about  to  come  to  a 
conclusion. 

699.  The  shape  of  the  os  uteri  during  the  process  of  dilatation  is 
no  less  variable  than  the  thickness  of  its  lips.  It  is  pretty  nearly 
circular  where  it  corresponds  to  the  centre  of  the  pelvis ;  but  more 
commonly  it  is  oval,  with  the  broadest  part  turned  backwards,  or  to 
one  side,  right  or  led,  according  as  the  fundus  is  inclined  in  this  or 
that  direction ;  sometimes  elliptical,  especially  when  the  child  pre- 
sents in  a  transverse  direction,  it  exhibits,  in  other  cases,  certain 
inequalities  which  depend  upon  its  different  points  not  having  the 
same  consistence  nor  the  same  extensibility. 

700.  All  those  authors  who  have  maintained  that  the  foetus  is  the 
efficient  cause  of  delivery,  have  necessarily  also  admitted  that  it  is 
the  cause  of  the  dilatation  of  the  os  uteri.  The  common  people, 
mostly,  still  reason  in  this  way,  and  Vigarous  seems  to  be  of  the 
same  way  of  thinking ;  but  since  it  has  been  ascertained  that,  in  the 
expulsion  of  the  whole  or  part  of  a  dead  fcEtus,  the  os  uteri  dilates 
just  as  it  does  for  a  living  child,  this  opinion,  now  become  superan- 
nuated, has  been  completely  rejected.  We  have,  says  A.  Petit,  one 
decisive  proof  that  the  fajtus  does  not  dilate  the  orifice,  in  the  fact, 
that  if  we  place  a  finger  on  the  point  of  the  ovum  where  it  tends 
strongly  to  engage  in  the  opening,  we  find  that  the  head  of  the 
foetus,  instead  of  pressing  into  it,  actually  retires  from  below  up- 
wards, being  repelled  by  the  fluids  which  pass  betwixt  it  and  the 
womb  in  order  to  fill  up  the  bag  of  waters. 

This  however  does  not  imply  that  the  child  has  nothing  to  do  with 
the  production  of  this  phenomenon,  but  merely  that  it  is  not  the 
active  cause  in  it,  and  can  only  concur  in  it  by  being  under  the  in- 
fluence of  some  other  power. 

701.  The  real  cause  of  it  is  to  be  found  in  the  contractions  of 


LABOUR-PAINS.  377 

the  womb.  It  is  of  the  essence  of  fleshy  fibres  to  shorten  themselves, 
and  tend  to  approach  a  straight  line,  when  they  contract ;  the  womb  is 
composed  of  curved  fibres,  the  most  numerous  and  strongest  of  which 
occupy  its  fundus  and  body,  and  are  principally  placed  lengthwise ; 
the  cervix  is  the  weakest  part  of  the  whole  organ ;  the  ovum  is  an  in- 
compressible body.  Now,  it  is  manifest  that  with  such  a  disposition, 
the  dilatation  of  the  cervix  must  commence  with  the  contractions  of 
the  womb.  The  vertical  and  oblique  fibres,  by  their  two  extremities, 
which  are  their  movable  points,  draw  the  horizontal  fibres  to  which 
they  are  attached,  or  with  which  they  are  interlaced,  upwards  to- 
wards their  middle,  where  is  to  be  found  the  real  fixed  point.  The 
transverse  fibres,  in  contracting  upon  the  ovum,  a  smooth  oval  body, 
necessarily  tend  to  slide  towards  its  apex  or  towards  its  base;  but 
as  they  are  at  least  as  numerous  above  as  below  the  middle  trans- 
verse zone,  it  follows,  that  the  circular  fibres  of  the  inferior  portion 
of  the  uterus  will,  in  any  general  contraction,  be  found  to  resist, 
alone,  the  efforts  of  all  the  longitudinal  and  circular  fibres  of  its  su- 
perior half. 

On  the  other  hand,  as  the  ovum  can  only  be  pushed  by  the  con- 
cavity of  the  uterine  fibres  towards  the  least  resisting  point  of  the 
organ,  it  engages  in  the  partly  open  orifice,  and  becomes  a  powerful 
though  secondary  cause  of  the  dilatation  of  the  os  uteri,  and  in  this 
case  acts  like  a  wedge  ;  it  is  an  inert  force  which  acts  in  aid  of  a 
vital  or  organic  force.  Thus  it  may  be  admitted  that  the  ovum  is 
depressed  while  the  os  uteri  is  raised  upwards  ;  in  other  words,  that 
these  two  parts,  under  the  influence  of  the  same  power,  the  uterine 
contraction,  slide  one  upon  the  other,  and  that  the  latter  must 
dilate  in  the  direct  ratio  of  the  force  which  causes  the  former  to 
descend. 

At  the  commencement  of  labour,  when  the  os  uteri  just  begins  to 
open,  it  is  known  to  contract  instead  of  dilating  during  the  pain,  but 
in  such  a  way,  notwithstanding,  that  it  remains  larger  after  the  pain 
than  it  was  before  it.  At  a  more  advanced  stage,  when  the  bag  of 
waters  begins  to  form,  we  observe,  on  the  contrary,  that  the  os  uteri 
dilates  considerably  during  the  contraction,  and  contracts  somewhat 
as  soon  as  it  is  over.  The  cause  of  this  peculiarity  is  easy  to  be 
understood  :  at  the  commencement,  the  fibres  of  the  neck  still  resist 
with  great  energy  the  action  of  the  fibres  of  the  body  and  fundus  ; 
as  the  womb  contracts  at  all  points  at  the  same  time,  and  not  in  one 
or  another  of  its  planes,  as  A.  Leroy  supposed,  or  in  difl^erent  por- 
tions of  its  substance  alternately,  as  taught  by  some  others,  the  orifice, 
instead  of  dilating  so  as  to  allow  the  membranes  to  engage,  on  the 
contrary  contracts,  as  if  to  prevent  their  passing  out ;  whereas,  at  a 


278  LABOUR-PAINS. 

more  advanced  stage,  when  it  is  sufficiently  open  to  permit  the  point 
of  the  ovum  to  lodge  in  it,  the  bag  of  waters  unites  in  assisting  the 
uterine  contraction  to  force  them  to  distend. 

702.  Immediately  after  the  discharge  of  the  liquor  amnii,  the  head 
of  the  foetus  occupies  the  situation  of  the  bag  of  membranes,  fulfils 
its  uses,  and  acts  upon  the  neck  in  the  same  manner ;  nearly  all 
practitioners  think  this  part  less  favourable  for  the  dilatation  than 
the  segment  of  the  membranes,  inasmuch  as  it  is  not  so  even,  as  it 
does  not  form  a  tumour  so  equally  stretched  ;  but  we  shall  see,  in 
examining  the  subject  of  the  premature  rupture  of  the  ovum,  that 
upon  this  subject  observation  requires  to  be  consulted  anew.  It  is 
principally  from  this  very  moment  that  the  uterine  circle  is  con- 
verted, in  first  labours,  into  a  circular  cushion  of  various  thickness, 
and  that  the  dilatation  seems  sometimes  to  diminish  to  such  a  degree 
as  to  impress  us  with  a  belief  that  the  labour  is  retrograding  instead 
of  advancing. 

§.  VI.  Of  the  discharge  of  glairy  mucus. 

703.  The  term  glairy  or  mucous  discharge  is  given  to  certain 
flakes  of  matter  of  a  very  clear  yellow  or  greenish  white  colour  which 
escape  from  the  sexual  organs  during  labour :  this  glairy  matter  occa- 
sionally resembles  white  of  egg  slightly  cooked,  and  diflfers  from  the 
mucus  of  the  nostrils  by  being  less  adhesive  and  by  forming  masses 
or  lumps  which  are  less  coherent  and  more  albuminous.  It  escapes 
in  masses  or  flakes  which  tremble  like  jelly,  come  away  especially 
during  the  contractions,  appear  in  some  instances  several  days  be- 
fore the  onset  of  labour,  of  which  they  constitute  one  of  the  most 
certain  preliminary  signs*,  become  more  and  more  abundant  as  the 
dilatation  progresses,  and  at  last,  in  a  majority  of  M'omen,  become 
tinged  with  blood. 

704.  Nothing  is  more  variable  than  the  quantity  of  this  discharge ; 
sometimes  a  few  lumps  only  are  observed,  and  at  others  very  large 
quantities  of  it  escape  with  each  pain ;  when  in  small  quantity 
or  wholly  wanting,  the  labour  is  said  to  be  a  dry  one;  when  abun- 
dant, it  leads  us  to  believe  the  labour  will  be  soon  terminated. 
Where  red  striae  are  mixed  with  it,  the  woman  is  said  to  have  a 
*how^  and  the  bystanders  think  it  a  good  sign  ;  or  a  proof  that  the 
labour  will  be  quickly  over.  This  notion,  although  not  without  some 
foundation,  for  it  is  generally  observed  about  the  close  of  the  first 
stage,  is  far  from  being  always  correct;  because  there  are  cases 

*  In  a  great  many  animals,  both  domestic  and  wild,  parturition  is  also  preceded 
by  a  diacharge  of  mucous  matters,  which  is  sometimes  very  abundant. 


DISCHARGE  OF  GLAIRY  MUCUS.  279 

where  the  red  coloured  mucus  does  not  appear  at  all,  while  there 
are  others  in  which  it  occurs  with  the  first  pains. 

705.  Some  authors  have  supposed  that  this  semi-fluid  matter 
escapes  by  transudation  from  the  membranes,  and  upon  leaving  the 
ovum  becomes  thickened  in  consequence  of  the  increased  tempera- 
ture of  the  parts  of  generation ;  as  if  there  was  the  least  resemblance, 
either  as  to  nature  or  appearance,  between  the  water  of  the  amnios 
and  the  mucous  discharges!  Others  have  believed  that  the  fluids 
brought  to  the  external  surface  of  the  ovum,  meeting  only  with  vessels 
of  extreme  tenuity  whereby  to  penetrate  within  the  amnios,  decom- 
pose, become  in  some  measure  filtered,  and  that  their  finest  and  most 
subtle  particles  pass  through  the  membranes  to  form  the  waters;  while 
their  grosser  principles  remain  without,  accumulate  in  the  vessels 
nearest  the  internal  surface  of  the  womb,  whence  they  are  expelled 
during  the  contractions  to  give  rise  to  the  glairy  discharges  ;  but  such 
an  hypothesis  need  only  be  mentioned  in  order  to  show  its  futility. 
The  glairy  matter  is  furnished  by  the  mucous  membrane,  and  I  cannot 
conceive  why  its  source  should  have  been  looked  for  any  where  else. 
The  vagina  is  lubricated  with  it  every  moment  during  the  lifetime 
of  the  individual ;  many  women  discharge  pretty  large  flakes  of  it 
at  the  approach  of  the  catamenias  ;  it  is  not  uncommon  to  find  the 
womb  filled  with  it  in  women  who  die  in  the  unimpregnated  state  ;  in 
leucorrhoea  and  other  diseased  states,  it  sometimes  exhibits  the  same 
characters,  and  runs  ofl"  in  as  large  quantity  as  during  labour  ;  finally, 
if  it  be  of  the  very  essence  of  organs  lined  with  mucous  membranes 
to  secrete  mucus,  is  it  surprising  that  some  of  it  should  be  formed 
in  the  sexual  organs  during  labour  ? 

706.  The  blood  mixed  with  it  comes  neither  from  a  rupture  of 
the  utero-placental  vessels,  for  these  vessels  have  no  existence,  nor 
from  slight  lacerations  of  the  cervix,  at  least,  most  generally ;  for  it 
is  very  common  to  find  the  bloody  mucus  appear  before  the  cervix 
has  been  at  all  stretched  :  the  mucus  is  coloured  with  blood  in  the 
same  manner  as  the  sputa  in  cases  of  pulmonic  irritation,  or  as  the 
mucous  excretions  of  the  nose  in  cases  of  irritation  seated  in  the 
schneiderian  membrane,  &c.  Whether  this  blood  be  derived  from 
the  interior  of  the  womb,  or  even  from  some  cracks  in  the  cervix 
uteri,  it  may  be  conceived  that  though  it  ordinarily  goes  only  so  far 
as  to  redden  the  mucus,  it  may  nevertheless  go  to  a  much  greater 
extent,  so  as  to  constitute  a  real  hemorrhage. 

707.  The  use  of  the  glairy  matter  is  to  moisten  and  lubricate  the 
parts  over  which  the  child  has  to  pass,  to  increase  their  suppleness 
and  extensibility,  and  make  it  more  easy  for  the  ovum  to  slide  over 
the  surfaces.     Where  the  discharges  fail  to  take  place,  the  dilatation 


280  DISCHARGE  OF  GLAIRY  MUCUS. 

of  the  OS  uteri  is  always  more  painful,  slower,  and  the  organs  more 
disposed  to  become  inflamed  ;  their  superabundance,  in  general,  in- 
dicates great  softness  of  the  tissues,  weakness  and  a  disposition  to 
inertia  ;  so  that  this  phenomenon  really  deserves  great  attention  in 
practice,  and  the  accoucheur  ought  carefully  to  study  its  progress 
and  its  particular  modifications. 

§.  VII.  Of  the  bag  of  waters. 

708.  The  name  of  bag  of  waters  is  given  to  the  protuberance 
formed  by  the  membranes  in  the  upper  part  of  the  vagina  during 
labour.  A  true  segment  of  a  sphere,  or  of  an  ovoid  figure,  which 
was  compared  by  A.  Petit  to  a  tymbal,  this  sac  varies,  however,  in 
respect  to  its  shape,  for  it  is  generally  moulded  upon  the  opening 
through  which  it  tends  to  escape.  Round,  globular,  and  even,  where 
the  OS  uteri  corresponds  to  the  centre  of  the  pelvis,  and  dilates  in  a 
regular  manner,  commonly  elliptical,  where  the  child  presents  trans- 
versely, wider  behind  and  to  the  right  or  left  in  cases  where  the 
womb  is  strongly  inclined  in  the  opposite  direction,  it  sometimes 
presents  the  appearance  of  a  cone,  somewhat  elongated,  or  of  a 
portion  of  intestine,  or,  as  it  is  called,  the  shape  of  a  saussage  or 
blood  pudding,  particularly  when  the  foetus  presents  by  the  feet,  or 
also  where  the  os  uteri  is  very  hard  at  the  same  time  that  the  mem- 
branes exhibit  a  great  degree  of  extensibility  ;  it  has,  finally,  been 
seen  to  enlarge  beneath  the  orifice  and  become  pyriform. 

709.  During  the  presence  of  a  pain  the  bag  of  waters  is  hard, 
tense,  and  elastic ;  after  the  contraction  is  over  it  becomes  wrinkled 
and  contracts  or  disappears.  Constituted  like  the  rest  of  the  ovum 
of  the  anhistous  membrane,  the  chorion  and  amnios,  its  formation, 
according  to  some  persons,  depends  upon  the  elongation  of  the 
membranes  ;  but  A.  Petit  has  fully  refuted  this  opinion,  by  demon- 
strating that  the  fcetal  tunics  are  scarcely  extensible  ;  according  to 
some  other  writers,  and  particularly  the  last  named  author,  every 
contraction  causes  a  small  quantity  of  water  to  exude  from  them  out- 
wards ;  a  vacuum  is  gradually  effected  in  the  amnios  ;  and  the  ovum, 
being  powerfully  pressed  in  all  directions,  gradually  engages,  through 
the  orifice,  in  the  upper  part  of  the  vagina  ;  but  if  this  transudation 
really  took  place,  the  surface  of  the  bag  would  become  covered  with 
small  drops  of  water  or  a  kind  of  dew,  in  a  word,  it  would  become 
moist,  during  the  pains,  whereas  it  is  never  drier  than  it  is  during  the 
very  strongest  contractions;  besides,  it  has  already  been  seen  that 
there  is  no  analogy  between  the  liquor  aninii  and  the  glairy  dis- 
charges, into  the  composition  of  which  A.  Petit  gratuitously  sup- 
posed them  to  enter  so  readily. 


BAG  OF  WATERS.  2S1 

710.  The  bag  of  waters,  like  the  dilatation  of  the  cervix,  is  pro- 
duced by  the  contractions  of  the  womb,  and  by  a  mechanism  equally 
easy  to  be  understood  :  by  acting  upon  the  periphery  of  the  ovum  as 
upon  the  throat  of  a  pulley,  the  uterine  fibres  compel  it  to  descend, 
while,  on  the  other  hand,  the  cervix,  by  dilating,  is  obliged  to  ap- 
proach nearer  to  the  fundus,  and  to  leave  a  more  or  less  considerable 
segment  of  the  membranes  outside  of  the  orifice ;  the  point  of  the 
foetal  ovoid,  lubricated  with  mucus,  forces  the  orifice  to  open  a  little, 
as  the  finger,  when  previously  covered  with  a  peach  skin  turned  in- 
side out,  will  force  the  fingers  of  the  other  hand  to  open  when  we 
try  to  push  it  betwixt  them.  It  would,  notwithstanding,  be  wrong 
absolutely  to  deny  the  extensibility  of  the  tunics  of  the  foDtus.  On 
the  contrary,  every  thing  proves  that  they  may  sometimes  extend  to 
a  considerable  degree,  and  that  it  is  in  consequence  of  this  elonga- 
tion that  the  bag  in  certain  cases  afiects  the  form  of  a  cone  or  of  a 
pear  ;  I  merely  wish  to  say  that  this  property  is  in  general  very  slight. 
Even  if  it  be  true  that  the  amniotic  tymbal  is  almost  always  curved 
upon  a  cord  that  is  shorter  than  the  rest  of  the  ovum,  it  is  also  true 
that  this  peculiarity,  which  seems  to  demonstrate  that  the  membranes 
have  yielded  at  that  point,  is  owing  to  another  cause  ;  any  one  who 
has  had  occasion  carefully  to  open  a  pregnant  womb,  has  had  an 
opportunity  of  being  convinced  that  the  mere  weight  of  the  ovum  is 
sufiicient  to  flatten  it  very  considerably,  as  soon  as  it  ceases  to  be 
exactly  supported  by  the  surrounding  organs  :  therefore,  it  is  quite 
evident  that  a  portion  of  the  membranes  may  in  this  state  of  relaxa- 
tion engage  very  well  in  the  os  uteri,  and  in  a  very  small  volume, 
without  undergoing  any  real  elongation. 

711.  After  having  wholly,  or  in  part,  dilated  the  os  uteri,  the  bag 
of  waters,  now  become  very  large,  and  besides,  ill-supported  in  the 
upper  part  of  the  vagina,  yields  to  the  impulsion  of  the  liquid,  an 
breaks ;  the  contained  fluid  escapes,  and  the  head  of  the  child  beiu] 
at  the  same  moment  pushed  forwards  by  the  same  effort,  stops  up 
the  passage  to  the  rest  of  the  liquor  amnii.  But  this  rupture  is  far 
from  always  taking  place  at  the  same  point,  or  under  the  same  de- 
gree of  dilatation,  or  at  the  same  stage  of  labour  in  all  women.  The 
membranes  may  be  too  dense,  too  thick  and  too  resisting,  or  too 
thin  and  fragile  ;  the  os  uteri  itself,  which  is  sometimes  very  hard, 
rigid,  and  difficult  to  distend,  is,  on  the  contrary,  in  other  cases  ex- 
tremely soft.  In  the  most  natural  and  regular  state  of  things,  the 
sac  gives  way  about  the  end  of  the  first,  or  commencement  of  the 
second  stage  ;  but  it  may  open  at  the  beginning,  or  not  till  the  end 
of  the  labour.  It  happens  also,  sometimes,  that  the  membranes  burst 
either  one  or  several  days  before  the  appearance  of  the  first  pains, 

2L 


282  BAG  OF  WATERS. 

or  that  they  do  not  rupture  at  all,  the  ovum  being  forced  to  pass 
whole  through  the  straits  of  the  pelvis. 

The  perforation  commonly  takes  place  in  the  centre,  and  in  that 
case  the  sac  becomes  instantly  empty  ;  if  it  happen  near  the  edge 
of  the  orifice  or  high  up,  it  collapses  only  imperfectly,  or  appears 
again  with  each  return  of  the  pains,  and  the  fluid  escapes  in  small 
quantities  only.  When  the  tumour  does  not  open  until  it  nearly 
reaches  the  vulva,  and  the  rupture  does  not  take  place  in  the  centre, 
the  head  carries  a  segment'of  the  membrane  along  before  it,  and  the 
foetus  escapes  covered  with  a  sort  of  hood,  and  is  born  with  a  caul. 

712.  It  was  formerly  predicted  that  a  child  born  in  this  way 
would  be  lucky  or  unlucky  according  to  the  colour  of  the  caul ; 
that  if  it  swallowed  its  caul  previously  reduced  to  powder,  or 
always  carried  it  about  its  person  carefully  enclosed  in  a  box,  it 
would  be  fortunate  and  always  happy  ;  that  if  it  lost  it,  it  would  be 
unhappy  in  every  thing,  perhaps  epileptic,  constantly  tormented  by 
phantoms  or  infernal  spirits  ;  whence  it  follows,  says  Diemerbroeck, 
that  the  midwives  seize  upon  this  portion  of  membrane  as  a  matter 
of  right,  in  order  to  frighten  the  parents,  and  get  more  money  from 
them  by  selling  it  to  them  at  a  dear  rate.  How  many  good  women 
in  the  country  are  still  imbued  with  this  absurd  prejudice  !  Should 
the  caul  extend  over  the  mouth  and  nose,  it  might,  strictly  speaking, 
hinder  respiration  from  taking  place,  and  perhaps  cause  the  death  of 
the  child,  as  some  authors  have  supposed  ;  but  to  justify  such  fears 
as  tliese,  the  lying-in  woman  herself  must  be  supposed  to  be  insen- 
sible, and  to  have  no  body  with  her  :  this,  therefore,  is  one  of  those 
possible  misfortunes  of  which  we  are  as  yet  in  possession  of  no  ex- 
amples. 


ARTICLE  II. 

Of  Eutocia,  or  Simple,  Fortunate,  or  Spontaneous  Labour 
(natural  labour  of  the  French  writers). 

In  order  that  labour  may  terminate  without  foreign  aid,  a  consi- 
derable number  of  conditions  are  required. 

713.  On  the  part  of  the  woman,  there  must  be  no  fault  nor  de- 
formity in  the  pelvis  ;  no  serious  affection  of  the  womb,  no  scirrhus 
nor  old  cicatrices  ;  the  organ  must  enjoy  a  certain  degree  of  energy  ; 
the  general  powers  of  tiie  system  must  not  have  been  exhausted, 
either  by  a  profuse  hemorrhage,  or  any  long  continued  disease  ; 


EUTOCIA.  283 

there  must  be  no  affection,  making  it  dangerous  for  the  woman  to 
.  give  herself  fully  up  to  the  efforts  she  is  compelled  to  make,  and  no 
^  accident  must  supervene  during  the  labour. 
Jk      714.  On  the  part  of  the  child,  it  is  important  that  the  occipito- 
■  ^  coccygeal  axis  should  present  one  of  its  extremities  to  the  straits, 
that  the  foetus  should  descend  with  the  head,  the  feet,  the  knees  or 
the  breech  foremost ;  that  it  should  not  be  hydrocephalous,  gibbous 
or  ascitic  ;  not  of  a  size  disproportioned  to  the  capacity  of  the  pel- 
vis ;  that  there  be  not  two  heads  attached  to  a  single  trunk,  or  two 
trunks  to  a  single  head,  nor  two  children  united  together  in  any 
manner  whatever. 

716.  Notwithstanding  the  number  of  these  conditions,  it  is  a  rare 
thing  for  them  not  to  be  met  with  ;  for  spontaneous  child-birth  forms 
a  large  proportion  of  the  sum  total  of  labours.  We  find  in  Merri- 
man's  Synoptical  Table,  that  out  of  1800  cases  1746  might  have 
terminated  spontaneously,  since  the  child  presented  by  the  vertex  in 
1664  instances,  four  times  by  the  lower  extremities,  twenty-three 
by  the  face,  forty-two  by  the  hip,  and  that  in  twenty-three  cases  the 
labour  was  only  regarded  as  dystocial  because  they  were  multiparoua 
pregnancies.  20,357  labours  took  place  at  the  Maternite  at  Paris 
from  1797  to  the  end  of  1811  ;  of  these  20,183  were  natural.  Out 
of  1897  that  took  place  under  the  superintendence  of  Dr  Bland, 
1860  were  brought  to  a  conclusion  by  the  hand  of  nature.  It  is 
seen,  therefore,  that  at  the  Maison  d' Accouchement  at  Paris,  diffi- 
cult labours  have  occurred  in  the  proportion  of  one  to  sixty-two  ; 
and  at  the  Westminster  Dispensary  and  Middlesex  Hospital,  accord- 
ing to  Merriman  an,d  Bland,  out  of  forty-three  labours,  forty-two 
terminate  spontaneously. 

Madame  Lachapelle,  in  her  new  tables,  divides  the  labours  that 
have  fallen  under  her  notice  into  two  periods  ;  the  first,  extending 
from  the  1st  Germinal,  year  IX,  to  the  31st  December  1811,  com- 
prises 15,662  cases,  of  which  15,380  were  spontaneous,  and  two 
hundred  and  seventy-two  difficult ;  the  second,  which  extends  from  the 
1st  of  January  1812  to  the  31st  December  1820,  comprises  22,243 
labours,  of  which  21,974  terminated  without  any  artificial  assis- 
tance, and  two  hundred  and  sixty-nine  by  the  assistance  of  art. 
According  to  Boer,  there  were  958  cases  from  September  1 787  to  the 
same  period  in  1790,  in  the  Obstetrical  School  of  Vienna  ;  and  of 
this  number  seventeen  required  turning,  the  forceps,  or  the  perforation 
of  the  head  ;  from  September  1790  to  September  1791,  there  were 
eighteen  cases  of  dystocia  out  of  950  labours  ;  from  September  1791 
to  September  1792,  out  of  1016  labours,  there  were  eight  requiring 
turning,  and  seven  the  forceps  ;  from  the  1st  January  1801  to  31st 


284  EUTOCIA. 

December  1 802,  among  2234  labours,  thirteen  were  concluded  by 
turning,  eight  by  forceps,  and  two  by  the  perforation  of  the  head  ; 
from  January  1st,  1803  to  December  31st,  1805,  out  of  2,399 
labours  there  were  five  cases  of  turning,  eleven  of  application  of  the 
forceps,  and  three  of  perforation  ;  in  1806,  out  of  2030  cases,  seven 
required  turning,  two  the  forceps,  and  one  the  perforation  of  the  head. 
At  Heidelberg,  out  of  1296  labours  mentioned  by  M.  Na^gele,  1230 
were  natural,  and  sixty-four  not  natural ;  which  gives  the  proportion 
of  one  to  twenty,  wliile  the  view  by  Boer  exhibits,  upon  a  total  of  9590 
only  102  requiring  turning,  the  employment  of  the  forceps,  or  the  per- 
foration of  the  head ;  which  makes  about  one  case  of  dystocia  in 
ninety-five.  But  these  proportions  must  be  understood  only  as  show- 
ing the  practice  of  the  authors  who  have  published  them,  and  not 
practice  out  of  the  public  establishments.  The  discrepancies  now 
existing  in  reports  on  this  head  are  already  sufficiently  great ;  as  may 
be  evident  upon  reference  to  the  London  and  Paris  reports,  and 
those  of  M.  Boer,  and  those  of  the  clinic  at  Pavia,  for,  accord- 
ing to  M,  Lovati,  out  of  sixty-seven  labours,  twenty-two  re- 
quired to  be  assisted.  However,  the  proportions  found  in  private 
practice  are  still  more  variable,  for,  in  great  cities  as  well  as  in  the 
country,  the  resources  of  art  are  called  in,  at  least  in  one  case  in 
six,  by  some  individuals,  whilst  others  employ  them  only  once  in 
ten,  twenty,  or  thirty,  or  even  sixty,  eighty  or  one  hundred  cases. 

716.  Admitting  the  result  of  the  last  period  mentioned  by  the 
Vienna  professor,  as  the  farthest  possible  limit,  as  the  last  term,  and 
beyond  which  nature  cannot  pass,  we  ask,  can  we  rely  upon  enjoy- 
ing equal  advantages  ?  On  this  subject  I  think  it  important  that 
we  should  not  confound  the  possible  with  the  useful.  Although 
Boer's  work  proved  that  only  one  case  out  of  one  hundred  and 
thirty-two  labours  was  terminated  by  the  assistance  of  art,  it  does 
not  by  any  means  prove  that  it  would  not  have  been  better  to  have 
had  recourse  to  it  in  some  other  of  the  hundred  and  thirty-one  cases. 
Is  it  not  certain  (hat  in  many  cases  where  parturition  may,  rigorously 
speaking,  take  place  spontaneously,  nature  would,  by  a  proper  kind 
of  assistance,  conclude  the  function  more  happily  both  for  the  mo- 
ther and  the  child  ?  As  to  Merriman  and  Bland,  who  mention  one 
case  of  dystocia  out  of  forty-five,  it  is  not  proved  that  they  were  not 
in  a  hurry  to  act  in  many  cases  where  the  organism,  if  left  to  itself, 
would  have  fully  sufficed  for  its  own  welfare  ;  besides,  every  body 
knows  that  patience  is  not  the  prevailing  quality  of  English  practi- 
tioners. Be  this  as  it  may,  if  the  results  obtained  in  the  hospitals 
of  Vienna  and  London  be  taken  as  the  two  extremes,  it  seems  to 
me  that  we  may  admit  those  of  the  Maternit6  at  Paris  to  be  the 


EUTOCIA.  285 

mean  term,  and  then  it  will  appear  that  the  active  co-operation  of 
the  accoucheur  will  be  useful  in  one  out  of  fifty  or  sixty  cases. 

7 1 7.  Now  what  is  the  reason  that  a  different  result  is  found  to 
occur  in  private  practice  ?  Ought  dystocia  to  be  met  with  more 
frequently  in  women  in  easy  circumstances,  who  live  well  in  their 
own  families,  than  in  the  poor,  who  are  tormented  with  fear  or  re- 
morse, and  who  go  to  the  hospitals  to  be  confined  ?  No,  doubtless ; 
for  every  thing  concurs  to  increase  the  number  of  difficult  labours 
in  the  hospitals,  and  diminish  it  in  private  practice.  Deformed  pel- 
vis and  all  sorts  of  diseases  of  the  genital  organs  are  most  frequently 
to  be  met  with  among  the  poorer  class  of  women  ;  many  women, 
who  would  otherwise  have  remained  at  their  own  houses  to  be  de- 
livered, go  to  lie-in  at  the  hospital,  because  they  are  of  a  bad  con- 
formation, or  because  they  are  fearful  of  having  a  dangerous  labour ; 
many  others  go  there  while  in  labour,  because  they  are  found,  by  the 
person  originally  called  in,  to  need  the  assistance  of  art,  and  because 
they  will  have  an  opportunity  of  receiving  that  assistance  better  than 
they  would  at  home. 

718.  But  in  the  hospitals  none,  in  general,  except  skilful  persons, 
are  appointed,  who  do  not  act  for  the  mere  pleasure  of  doing  so, 
who  repose  in  nature  all  the  confidence  that  she  deserves,  and  do 
not  vainly  interfere  to  assist  her  to  do  better ;  who  know  how  to 
apply  in  proper  season,  and  only  where  they  are  indispensable,  or 
at  least  evidently  useful,  the  resources  of  an  art  whose  fundamental 
principle  is,  always  to  preserve,  and  never  to  destroy,  except  in 
cases  of  absolute  necessity.  But  out  of  those  public  institutions,  how 
many  imprudent,  ill-timed,  unskilful,  or  rash  maneuvres !  Here  it 
is  an  ignorant  midwife,  whose  audacity  and  effrontery  supply  the 
place  of  knowledge,  who  cannot  remain  unemployed  about  the  un- 
fortunate women  who  are  so  thoughtless  as  to  confide  in  her  ;  there, 
it  is  a  practitioner  not  less  inept  and  more  dangerous  than  the  old 
woman,  inasmuch  as  he  inspires  confidence  ;  such  men,  who  are, 
unfortunately,  too  numerous,  who  call  themselves  accoucheurs,  be- 
cause they  are  incapable  of  becoming  any  thing  else,  take  a  pride 
in  the  number  of  difficult  labours  that  they  have  terminated ;  they 
resolve  to  deliver  by  force,  without  giving  nature,  who  is  wiser 
than  themselves,  time  to  finish  her  work ;  and  so  that  they  may  but 
seem  to  be  necessary,  fear  not  to  obstruct,  interfere  with  and  tor- 
ment the  organs,  so  as  to  convert  the  most  natural  labour  into  a 
dangerous  one  I 

There  again,  it  is  an  impatient  practitioner,  who,  being  in  too 
great  a  hurry  to  wait,  needlessly  applies  the  assistance  of  art,  so 
as  to  be  sooner  at  liberty  to  pursue  his  occupation  somewhere  else. 


286  EUTOCIA. 

Sometimes  it  is  a  timid  young  physician,  who,  led  away  by  the  cries 
of  the  patient,  her  relations,  and  assistants,  rather  than  lose  the 
confidence  he  wishes  to  inspire,  decides  on  resorting  to  measures 
he  knows  to  be  useless.  Finally,  on  other  occasions,  there  are 
wretches,  equally  criminal  and  despicable,  who,  in  order  to  obtain 
reputation  among  the  people,  make  haste  to  operate  wherever  they 
suppose  they  can  profit  thereby,  without  thinking  upon  the  dangers 
to  which  they  expose  both  mother  and  child.  Such  scandalous 
conduct  as  this,  to  the  shame  of  the  authorities,  the  laws,  and  of 
the  establishments  for  instruction  be  it  spoken,  is  daily  observed  far 
more  in  the  large  cities  than  in  country  places. 

719.  "  I  feel  compelled,"  says  Diderot,  "  by  the  interest  that  every 
honest  man  ought  to  feel  in  the  birth  of  the  citizens,  to  declare,  that 
being  urged  by  curiosity,  I  caused  myself  to  be  conducted  one  day 
to  one  of  those  midwives  who  take  in  pupils,  and  that  I  there  wit- 
nessed samples  of  inhumanity  which  would  be  almost  incredible 
among  barbarians  ;  these  midwives,  in  hopes  of  attracting  a  greater 
number  of  spe-ctators,  and  consequently  of  peasants,  would  cause 
their  emissaries  to  announce  that  they  had  a  woman  in  child-birth,  and 
that  the  labour  would  certainly  prove  preternatural ;  the  spectators 
collected,  and  in  order  not  to  deceive  the  general  expectation,  they 
returned  the  child  into  the  womb,  and  brought  it  down  by  the  feet ! 
I  should  not  dare  to  state  this  fact  if  I  had  not  several  times  been  a 
witness  to  it,  and  if  the  midwife  had  not  the  impudence  to  confess 
it  to  me.  I  therefore  charge  those  who  are  appointed  to  watch 
over  the  disorders  of  society,  to  keep  their  eyes  upon  this  one." 

Would  to  Heaven  the  fact  related  by  Diderot  had  never  been  re- 
peated since,  and  that  it  had  never  been  witnessed  except  among 
midwives !  But  let  us  draw  a  veil  over  a  kind  of  conduct  which 
lends  but  too  much  support  to  the  idea  of  Denman,  '■'■  that  the  abuse 
of  art  produces  evils  more  numerous  and  serious  than  the  imperfec- 
tions of  nature." 

Such,  doubtless,  are  the  chief  causes  that  render  dystocia  more 
common  in  private  than  in  hospital  practice. 

720.  However,  it  must  be  confessed  that  the  proportions  between 
the  different  kinds  of  labour  must  of  necessity  vary  from  circum- 
stances wholly  accidental.  Thus,  of  two  practitioners  who  are 
equally  skilful  and  equally  circumspect,  one  may  attend  several 
hundred  labours  without  being  obliged  to  give  any  assistance  to  na- 
ture ;  while  the  other  may  be  several  times  obliged  to  have  re- 
course to  the  artificial  means.  Since  I  began  carefully  to  notice  the 
facts  that  have  fallen  under  my  own  notice  in  tokology,  I  have 
found  a  very  great  difference  between  what  has  occurred  at  my 


EUTOCIA.  287 

amphitheatre  and  in  my  private  practice.  Out  of  five  hundred  and 
fifty  labours  that  look  place  in  the  Hospital  de  Perfectionnement 
while  I  had  charge  of  it,  and  in  my  own  amphitheatre,  only  eight 
required  any  assistance  ;  in  my  private  practice,  on  the  contrary, 
out  of  less  than  three  hundred  cases,  I  had  thirty  cases  of  dystocia  ; 
which  gives  for  the  former  only  one  difiicult  labour  in  upwards  of 
sixty,  and  for  the  latter,  so  to  speak,  one  for  every  eight  labours. 
Such  a  disproportion  is,  however,  not  difficult  to  account  for ;  at 
my  public  hall,  and  at  the  hospital,  we  received  without  distinction 
all  the  women  who  presented  themselves,  without  any  of  them,  ex- 
cept tv/o,  having  previously  undergone  any  examination  ;  while  the 
cases  of  dystocia  that  fell  under  my  notice  elsewhere,  were  almost 
all  procured  for  me  by  my  brethren,  or  by  mid  wives,  who,  from  ex- 
cessive timidity,  or  for  want  of  practice  in  the  use  of  instruments,  pre- 
ferred calling  on  me  rather  than  to  attempt  to  deliver  the  women 
themselves. 


SECTION  1. 

Of  Natural  Eutocia  {simple  or  spontaneous  labour^  the  head  of  the 
child  presenting). 

721.  What  I  have  said  concerning  the  attitude  and  position  of 
the  foetus  in  the  womb,  makes  it  sufficiently  evident,  that  the  child 
ought  properly  to  present  its  cephalic  extremity  to  the  straits  of  the 
pelvis,  and  that  the  cases  where  it  descends  in  any  other  way  should 
be  regarded  only  as  anomalies.  It  was  correct,  therefore,  in  Hip- 
pocrates and  most  of  the  ancient  authors,  not  to  give  the  title  of 
natural  labours  except  to  those  in  which  the  head  of  the  child  came 
first,  and  to  call  all  labours  where  the  feet,  the  breech,  or  knees 
presented,  non-natural.  The  moderns  having  rejected  this  doctrine 
depends  upon  their  having  misconceived  the  acceptation  of  the 
terms :  the  word  natural  is  admitted  by  them  to  be  synonymous 
with  spontaneous^  and  consequently,  that  labour  where  the  pelvic 
extremity  presents  ought  to  belong  to  the  class  of  natural  labours. 

722.  There  is  no  doubt  that  the  principles  taught  by  the  father 
of  medicine  have  been  the  cause  of  important  errors  in  practice,  by 
leading  practitioners  to  deliver  by  the  head  when  it  did  not  origi- 
nally present,  and  in  denying  the  possibility  of  a  labour  terminating 
alone,  where  the  feet  present ;  but,  although  they  abandoned  these 
ideas,  have  not  the  authors  of  the  last  century  replaced  them  by 
others  equally  incorrect  ?  Is  it  right,  with  Dionis  and  A.  Petit,  to 
say  that  the  fcetus  may  be  extracted  with  as  much  or  more  ease  by 
drawing  it  away  by  the  feet,  than  if  it  descends  with  the  head  fore- 


2S8  NATURAL  EUTOCIA. 

most ;  and  that  it  is  almost  a  matter  of  indifference  as  to  the  result, 
whether  the  cephalic  or  pelvic  extremity  presents  ?  I  do  not  think 
so,  and  I  dare  to  say  that  such  a  way  of  thinking  would  be  scarcely 
less  dangerous  in  practice  than  the  ancient  doctrine.  There  is  no 
position  of  the  child  in  which  the  labour  has  not  sometimes  termi- 
nated alone ;  and  yet  it  has  entered  into  no  one's  head  to  call  a 
shoulder  presentation,  for  example,  a  natural  one.  If  a  dystocia 
takes  place,  it  is  not  because  the  child  is  in  this  or  that  position,  but 
because  'the  interference  of  art  becomes  indispensably  necessary ;  a 
labour  may  be  fortunate,  and  simple,  or  spontaneous,  although  the 
foetus  presents  with  its  pelvic  extremity ;  but  strictly  speaking,  the 
positions  of  the  head  are  alone  natural  or  normal. 

723.  Delivery  by  the  encephalic  extremity  contains  two  very  dis- 
tinct genera :  in  the  first  the  summit  of  the  head  presents  ;  while  in 
the  second,  the  face  or  some  other  part  of  the  head  offers  at  the 
straits. 

§.  I.  Presentation  of  the  vertex. 

1664  times  in  1800  cases  (Merriman);  1792  times  in  1897  cases 
(Bland);  19,730  in  20,357  cases  (Madame  Boivin);  14,677  times 
in  16,652  cases  (Madame  Lachapelle);  20,698  times  in  22,243  (Id.);- 
1210  in  1296  cases  (Najgele);  61  in  67  (Lovati);  392  in  400 
(Hospital  of  the  Faculty). 

724.  The  presentation  of  the  vertex  is  incomparably  more  fre- 
quent, as  may  be  seen  above,  than  all  the  others.  Is  any  thing  fur- 
ther wanting  to  prove  that  it  is  the  only  natural  one,  that  which  the 
organism  always  tends  to  produce,  when  nothing  arises  to  interfere 
with  the  regular  accomplishment  of  the  grand  act  of  reproduction? 
In  this  presentation  the  posterior  fontanel  tends  to  place  itself  in  the 
centre  of  the  pelvis.  Tlie  principal  diameters  of  the  straits  are 
adapted  to  the  occipito-bregmatic  and  bi-parietal  diameters.  The 
occipito-mental  diameter,  and  the  occipito-bregmatic  circumference 
should  be  parallel  to  the  planes  of  the  openings  of  the  excavation, 
and  to  the  axes  of  the  straits.  These  general  relations  are  always 
to  be  observed  in  regular  positions  of  the  vertex  ;  but  the  occiput  is 
far  from  looking  to  the  same  point  of  the  pelvic  circle  in  all  cases, 
whence  have  arisen  the  various  positions  at  present  admitted  in 
tokology. 

Antecedently  to  the  time  of  A.  Petit,  Solayrcs,  and  Baudelocqiic, 
accoucheurs  were  content  to  say  that  the  occiput  had  come  in  front 
or  backwards,  that  the  face  was  turned  towards  the  sacrum  or 
towards  the  pubis ;  and  this  old  method  of  considering  it,  which 
M.  Delpcch  defends,  is  still  generally  adopted  in  England,  in  Gcr- 


TABLE  IT. 


Positions  of  the  Foetus  according  to  different  Authors. 


Vertex. 


Face. 


Feet. 


Knees. 


Breech. 


Trunk. 


( I.  Occiput  behind  the  left  acetabnluni. 

2.  Occiput  behind  the  right  acetabulum. 

3.  Occiput  behind  the  symphysis  pubis. 

4.  Occiput  before  the  right  sacro-iliac  symphysis. 

5.  Occiput  before  the  left  sacro-iliac  symphysis. 
^6.  Occiput  before  the  sacrum. 

1.  Forehead  upon  the  symphysis  pubis. 

2.  Forehead  upon  tiie  sacro-vertebral  angle. 

3.  Forehead  upon  the  left  ileo-pectineal  eminence. 

.  4.  Forehead  upon  the  right  ileo-pectineal  eminence. 

1.  Heels  behind  the  left  acetabulum. 

2.  Heels  behind  the  right  acetabulum. 

3.  Heels  behind  the  symphysis  pubis. 

4.  Heels  in  front  of  the  sacrum, 

1.  Front  of  the  legs  behind  the  left  acetabulum. 

2.  Front  of  the  legs  behind  the  right  acetabulum. 

3.  Front  of  the  legs  behind  the  symphysis  pubis. 

4.  Front  of  the  legs  before  the  sacrum. 

1.  Sacrum  behind  the  left  acetabulum. 

2.  Sacrum  behind  the  right  acetabulum, 

3.  Sacrum  behind  the  symphysis  pubis. 

4.  Sacrum  in  front  of  the  promontory. 

{1.  Occiput 
2.  Neck. 
3.  Breast, 
4,  Loins. 
5.  Sacrum.         i.  Head  in  front. 
{1.  Face. 
2.  Neck.  2.  Head  behind. 

3.  Sternum.      . 
4,  Abdomen,  f  3.  Head  igft. 
5.  Genitals. 
{1.  Neck.  4,  Head  right 

2.  Shoulder.  ^ 

3.  Thorax. 
4.  Flank. 
5.  Hip. 


Vertex. 


Face. 


Feet.    . 

Knees. 

Breech. 


Trunk. 


Same  as  BAUi)£Locq,trE. 

1.  Forehead  left. 

2.  Forehead  right. 

3.  Forehead  front. 

4.  Forehead  back. 

1.  Heels,  legs,  or  sacrum  left. 

2.  Heels,  legs,  or  sacrum  right. 

3.  Heels,  legs,  or  sacrum  front. 

4.  Heels,  legs,  or  sacrum  back. 
Lateral  surface.     ^ 
Posterior  surface. 


'  No  subdivisions. 


Anterior  surface. 


1.  Head  left 

2.  Head  right. 

3.  Head  front. 

4.  Head  back. 


Vertex. 


Face. 


Feet. 


Knees. 
Breech, 


Trunk. 


TABLE  W.—Coniinued. 

Y  !•  I-eft  occipito-cotyloid. 
\  2.  Right  occi(>ilo-cotyloid. 
^  3.  Right  occipito  sacro-iliae. 
'  4.  Lett  occipito  sacro-iliac. 
Same  as  Gardien. 

SI.  Left  calcaneo-cotyloid. 
2.  Right  calcaneo-cotyloid. 
3.  Right  caleaneo  sacro-iliac. 
4.  Lett  caleaneo  sacro-iliac. 

<  Same  relations. 

I' Anterior  surface.  |J;  ^flf^^^ 

Back. — No  subdivisions. 

■1.  Hip. 
Lateral  surface.     -?  2.  Shoulder. 
Ear. 


(.3. 


■  Same  as  Gabs. 


Vertex. 


Feet.     . 

Knees. 

Breech. 


Face. 


V  Trunk. 


/-  1.  Left  occipito-anterior. 

\  2.  Right  occipito-anterior. 

\  3.  Right  occipito-posterior. 

f  4.  Left  occipito-posterior. 

r  1.  Left  caleaneo,  tibio,  or  sacro-anterior. 

\  2.  Right  caleaneo,  tibio,  or  sacro-anterior. 

i  3.  Right  caleaneo,  tibio,  or  sacro-poslerior. 

'  4.  Left  caleaneo,  tibio,  or  sacro-posterior. 

^  1.  Chin  behind  and  right. 

\  2.  Chin  behind  and  lelt. 

J  3.  Chin  in  front  and  left. 

'  4.  Chin  in  front  and  right. 

1.  Occiput. 

2.  Back. 

Anterior  surface,   ^g!  Breast. 

_,.  ,  ^ ,  .        J.        /-Side    of   the 
Right  lat.  surface,  \     ,j^^j 

wLeft  lat.  surface,     (.Shoulder. 


f  Posterior  surface. 


1.  Head  front  and  left. 

2.  Head  front  and  right 

3.  Head  back  and  right 

4.  Head  back  and  left. 


Vertex. 
Face.  . 


Feet.    . 

Knees. 

Breech. 


Trunk. 


Like  Gardient. 

1.  Mento-sacral 

2,  Mento-pubic. 

3,  Right  mento-iliac. 

4.  Left  raento-iliao. 


Like  Bauj)ei.ocq,U£, 


Sternal  surface,- 


Poster,  surface. 


^Lateral  surface. 


Like  BAUDELocdus ;  but  no  subdivision 

1.  Cervico-sacral. 

2.  Cervico-pubic. 
Right  oervico-iliac. 
Left  cervico-iliao. 
Costal  region. 
Region     of     the 
shoulder. 
Region  of  the  ear. 


'.4 


'  Like  Baud. 


o 


Vertex. 


,  Face.    .  . 

Feet.     .  . 

Kyiees.     . 

Breech.   . 

.  Shoulder. 


TABLE  n.— Continued. 

'1.    1st  of  BiUDELOCaUE. 

2.  Jdem. 

3.  4th  of  FiAUDElOCQUE.      • 

4.  5th  of  Bacdelocque. 

5.  Occiput  to  the  left, 
^  6.  Occiput  to  the  right 


•  lake  Baudelocquk. 


Moreover  there  are  intermediate, 
imperfect,  and  inclined  posi 
tions. 

.  No  other  position  of  the  trunk. 


'1.  Occipital  fontanel  above  the  left  acetabulum. 

2.  Occipital  fontanel  above  the  right  acetabulum. 

3.  Occipital  fontanel  above  symphysis  pubis. 
Vertex         i  **  0*^*^'l'''^l  fontanel  above  right  sacro-iliae  symphysis. 

'    ■     '-5,  Occipital  fontanel  above  left  sacro-iliac  symphysis. 

6.  Occipital  fontanel  above  sacro- vertebral  angle. 

7.  Occipital  fontanel  above  left  iliac  fossa. 
.  8.  Occipital  fontanel  above  right  iliac  fossa. 
Eight  species,  like  those  for  the  vertex. 


Breech. 


Trunk.    . 
4  surfaces. 


'Anter.  surface. 


<  Poster,  surface. 


Lat.  surfaces. 


C  1.  Cheek. 
>  2.  Neck. 
■j  3.  Shoulder. 
(  4.  Hip. 


1.  Head  to  the  left. 

2.  Head  to  the  right. 

3.  Head  in  front. 


4.  Head  behind. 


'  Vertex 4  positions,  like  MM.  Matghier  and  Capurgit. 

ri.  Loins  to  the  left. 
D«;„-  I        •..•         J  2.  Loins  to  the  right. 

^^^"^ -^  pos.t.ons.<^  3    Loins  in  front." 

\ji.  Loins  towards  the  back. 

Vertex  to  the  left.        ^ 
Vertex  to  the  right. 

Right  sh^.:   .     2  positions.  |^;«-^;^fE;,^. 
Left  shoulder...    2  posiUons.  |  ^;  ^^^  J^  ^^^^ 


Face. 2  positions.  <  „ 


Making 

i-iDall  14 

species. 


a 


^  s 


Vertex. 

Face. 

Feet. 

Knees. 

Breech. 

Trunk. 


f  Like  BAUDELocauE. 
Like  BAUSELOcauE,  except  the  subdivisions. 


TABLE  U.— Continued. 


r    Veftex. 
2  species. 


Head. 
2  species. 


Occip.-ant.  3var, 


Occip.-post.  3var, 


<  Face.  On\j~\ 

one  spe-  I  Mento-pubic.    4  va 
cies      at  >    rieties  at  the  supe- 
the     inf.  j      rior  strait, 
strait.      J 


Lower  end  of"] 
the   trunk, 
only      one  , 
kind :     the  1 
Pel-da.        J 


3  shades. 


Feet. 

Knees. 

Breech. 


} 


2  spec. " 


Trunk. 
3  genera. 


1.  Lateral  surface.     One  species. 

The  shoulder.     2  varieties. 

J  2.  Posterior  surface.  One  species. 

""      The  back.    2  varieties. 

3.  Anterior  surface.   One  species. 

The  breast.    2  varieties. 


1.  Left  occip.-acet. 

2.  Right  occip.-acet. 

3.  Occip.-pubie. 

1.  Left  fronto-acet. 

2.  Right  fronto-acet. 

3.  Fronto-pubic. 

1.  Right  mento-iliac 

2.  Left  mento-iliac. 

3.  Mento-pubic. 

4.  Mento-sacral. 

1.  Sacro-rl.  Left, 
ant.     ^2.  Right. 

3  var.    (.3.  Pubic. 

2.  Sacro-  rl.  Right, 
post.    <  2.  Left. 

3  var.    (.3.  Sacral. 

1.  Head  left. 

2.  Head  right. 

1.  Head  leth 

2.  Head  right. 

1.  Head  left. 

2.  Head  right. 


Besides  these,  there  are  inclined  positions  of  the  head,  1.  The  temple ; 
The  forehead ;  3.  The  occiput ;  and  of  the  breech  there  are,  1.  The 


hip;  2.  Sacrum;  3.  The  parts  of  generation 


PRESENTATION  OF  THE  VERTEX.  289 

ftiany,  and  in  most  foreign  countries.  It  is  therefore  in  France 
particularly,  and  almost  only  in  France,  that  attempts  have  been 
made  to  subject  labours  to  the  methods  followed  in  natural  history. 
But  upon  this,  as  upon  all  other  subjects  that  are  merely  matters  of 
convention,  it  has  happened  that  the  same  fact  has  not  been  looked 
at  in  the  same  light  by  all  observers.  In  the  opinion  of  some  we 
ought  to  admit  six  positions  of  the  vertex  ;  according  to  others,  the 
number  may  be  extended  to  twelve  and  even  to  twenty-four  ;  many 
think  that  there  should  be  only  four,  and  some  not  more  than  two. 
Again,  those  who  agree  in  respect  to  the  proper  number  differ  in 
regard  to  the  proper  method  of  counting  them  or  locating  them. 
For  example,  Madame  Lachapelle,  who  like  Baudelocque  admits 
of  six  positions,  does  not  adopt  the  two  antero-posterior  positions  of 
that  author,  but  in  place  of  them  establishes  two  transverse  positions, 
&.C. ;  so  that  it  is  a  pretty  difficult  matter  for  students  to  make  a 
choice  in  such  a  conflict  of  authorities. 

In  a  theoretical  point  of  view  it  cannot  be  denied  that  the  vertex 
may  present  itself  to  every  point  of  the  circumference  of  the  superior 
strait,  and  consequently,  that  an  infinite  number  of  positions  may  be 
established  if  we  choose ;  but  the  question  is,  how  many  of  them 
would  it  be  useful  to  adopt  in  practice,  which  are  those  we  ought 
to  study  with  particular  care,  and  not  how  many  we  might  admit. 
In  the  first  place,  it  is  evidently  superfluous  to  suppose  there  are 
more  of  them  than  there  are  points  corresponding  to  the  ends  of  the 
four  principal  diameters  of  the  pelvis ;  therefore  it  seems  that  the 
number  established  by  M.  Flamant,  and  which  unites  the  classifica- 
tion of  Baudelocque  with  that  of  Madame  Lachapelle,  might  be 
considerably  reduced.  In  fact,  the  occiput  scarcely  ever  presents  in 
more  than  two  ways  to  the  inferior  strait ;  in  one  it  looks  forwards 
and  lodges  under  the  arch  of  the  pubis ;  in  the  other,  it  is  turned 
backwards,  and  presses  the  anterior  edge  of  the  perineum  forcibly 
backwards. 

Agreeably  to  this  observation  I  have  thought  that  all  the  presentac-' 
tions  of  the  vertex  might  without  inconvenience  be  referred  to  two 
fundamental  positions  :  one,  in  which  the  occipital  protuberance 
answers  to  some  one  point  of  the  anterior  semi-circumference  of  the 
superior  strait ;  the  other,  where  the  same  part  is  turned  to  the 
opposite  portions  of  the  strait.  This  modification,  although  slight, 
and  in  itself  considered  of  very  little  importance,  answers,  notwith- 
standing all  the  wants  of  both  theory  and  practice ;  it  enjoys  the 
great  advantage  of  not  excluding  the  other  classifications,  and  of 
accommodating  itself  tb  all  the  various  doctrines. 

The  occipito-anterior  position  comprises  the  three  first  position* 
2M 


290  NATURAL  EUTOCIA. 

of  Baudelocque,  or  the  two  first  of  MM.  Maygrier,  Capuron 
and  Duges,  and  of  Mesd.  Boivin  and  Lachapelle.  The  occipito- 
posterior  position  naturally  includes  the  fourth,  fifth  and  sixth  of 
Baudelocque,  or  the  third  and  fourth  of  the  authors  just  now  men- 
tioned. As  to  the  lateral  positions  established  by  Madame  Lachapelle 
and  M.  Flamant,  they  are  at  least  very  rarely,  if  ever  to  be  met  with. 
It  is  evident  that  the  first,  second  and  third  have  one  common 
termination,  and  that  their  mechanism  is  in  almost  all  respects 
similar.  It  is  also  undeniable  that,  the  fourth,  fifth  and  sixth  do  not 
differ  more  than  the  others.  I  do  not  perceive,  therefore,  the  utility 
in  any  way,  of  admitting  these  varieties,  otherwise  than  as  so  many 
shades  of  the  two  fundamental  positions,  to  which  all  others  must 
of  necessity  be  at  last  reduced.  As  to  these,  I  think  that  no  one 
ever  attempted  to  confound  them  ;  their  mechanism  is  so  different, 
that  the  English  accoucheurs,  such  as  Burns,  Merriman  and  Bland, 
bestow  the  title  of  natural  labour  Only  upon  the  occipito-anterior 
position,  while,  according  to  them,  the  occipito-posterior  position 
belongs  to  the  class  of  preternatural  labour. 

1.  Occipito- Anterior  Position. 
1634  in   1800,  Merriman ;    19,370  in  20,517,  Madame  Boivin ;   14,253  in 
15,652,  20,268  in  22,243,  Madame  Lachapelle ;  60  in  67,  M.  Lovati. 

Many  foreign  practitioners  think  that  the  occipito-anterior  position 
is  the  only  one  we  ought  to  abandon  to  the  resources  of  nature. 
The  causes  of  its  great  frequency  are  wholly  physical  and  easy  to 
be  understood.  The  head  is  the  heaviest  part  of  the  foetus ;  the 
plane  of  the  neck  of  the  womb  is  always  lower  than  that  of  the 
fundus  ;  the  head  therefore  ought  to  incline  constantly  towards  the 
cervix  uteri.  The  posterior  half  of  the  head  is  much  more  weighty 
than  the  anterior  half.  The  weight  of  the  hinder  part  of  the  trunk, 
during  the  intra  uterine  life,  is  much  greater  than  that  of  the  an- 
terior portion.  When  the  woman  is  standing  up,  sitting  down,  or 
kneeling,  and  even  when  lying  on  her  side,  the  anterior  wall  of  the 
womb  is  much  more  inclined  towards  the  cervix  than  its  posterior 
wall ;  the  back  of  the  foetus  will  therefore  more  frequently  be  found 
turned  towards  the  front  of  the  mother  than  towards  hor  back.  In 
quadrupeds,  the  young  are  often  found  to  have  their  bellies  down- 
wards, and  almost  always  come  head  foremost,  although  the  womb 
is  lower  than  the  vulva  ;  but  it  is  to  be  observed  that  the  abdomen 
in  these  species  weighs  most,  and  the  head  least.  Another  no  less 
powerful  cause  of  the  frequency  of  this  position  is  found  in  the  pro- 
portional dimensions  and  inclinations  of  the  head  and  pelvis ;  the 


PRESENTATION  OF  THE  VERTEX.  291 

abdominal  strait  being  much  larger  in  front  than  behind,  and  strongly 
inclined  towards  the  pubis,  it  is  quite  natural  that  the  occiput  should 
commonly  assume  this  direction,  &.c.  The  cause  which  so  often 
directs  the  occiput  towards  the  anterior  semi-circle  of  the  strait,  is 
therefore  not  more  difficult  to  understand,  than  that  which  occasions 
the  head  to  descend  first ;  hence  physicians  were  wrong  to  abandon 
their  researches  in  relation  to  it.  ^ 

A.  First  Variety. 

Left  occipito-acetabular  position. 
1st  position  of  Baudelocque,  Maygrier,  Mesdames  Boivin  and  Lachapelle ; 
15,809  in  22,343,  Madame  Lacliapelle ;  15,693  in  20,517,  Madame  Boivin  ;  36 
in  67,  Lovati. 

In  this  position  the  back  of  the  foetus  looks  towards  the  front  and 
left  ;  its  abdomen  towards  the  back  and  right.  The  occiput  is  placed 
behind  the  corresponding  ileo-pectineal  eminence  much  more  fre- 
quently than  behind  the  acetabulum,  and  the  top  of  the  forehead  or 
the  anterior  fontanel,  rather  than  the  forehead  properly  so  called, 
looks  towards  the  right  sacro-iliac  symphysis ;  the  right  side  is  to 
the  right  and  in  front,  and  the  opposite  one  is  behind  and  towards 
the  left.  Its  great  frequency  seems  to  depend  upon  the  rectum  be- 
ing in  pregnancy  commonly  filled  with  faeces,  which  forces  the  fore- 
head to  incline  towards  the  right  side  ;  such  at  least  is'the  opinion 
of  accoucheurs  in  the  present  day  ;  an  opinion  which,  besides, 
seems  to  be  sustained  by  direct  observation,  since  M.  Duges  has 
seen  the  foetus  in  Baudelocque's  second  position  in  two  women 
who  had  the  rectum  on  the  right  side  :  but  this  point  is  wortliy  of 
new  researches. 

725.  In  this  position  the  head  of  the  child  does  not  pass  through 
the  pelvis  without  undergoing  four  particular  motions.  1st,  flexion  ; 
2d,  rotation  ;  3d,  extension  ;  4th,  restitution. 

Flexion.  Immediately  after  the  rupture  of  the  membranes,  the 
uterine  contractions  must  necessarily  press  the  several  parts  of  the 
foetus  upon  each  other  ;  being  pressed  from  above  downwards,  the 
spine  causes  the  head  to  bend  forwards  so  that  the  occiput  sinks 
towards  the  centre  of  the  pelvis,  and  the  chin  is  squeezed  more  or 
less  firmly  against  the  breast.  This  flexion  movement  does  not 
seem  to  have  been  well  understood,  even  by  the  most  esteemed 
authors.  They  teach  us  that  antecedently  to  the  very  first  contrac- 
tions of  the  womb,  the  head  should  be  disposed  in  such  a  manner, 
that  its  occipito-frontal  and  bi-parietal  diameters  should  be  parallel 
to  the  oblique  diameters  of  the  strait ;  whose  axis  would  then  be  re- 


^92  NATURAL  EUTOCIA. 

presented  by  the  vertical  diameter  of  the  fetus.  According  to 
them,  the  object  of  the  flexion  motion  would  be  to  alter  all  these 
relations  ;  that  is  to  say,  to  compel  the  occipito-mental  and  occipito- 
bregmatic  diameters  to  assume  the  places  of  the  vertical  and  occi- 
pito-frontal  diameters,  which  would  be  much  more  favourable.  In 
order  that  the  above  might  be  correct,  it  would  be  necessary  for  the 
chin,  during  pregnancy,  to  be  kept  habitually  remote  from  the  breast, 
which  it  would  not  approach  until  the  period  of  labour,  otherwise 
the  occipito-frontal  diameter  cannot  be  parallel  to  one  of  the  diame- 
ters of  the  pelvis  ;  but,  it  is  well  known  that  the  fcetus,  in  the  na- 
tural state,  is  always  doubled  up,  and  that  its  chin  is  pressed  upon 
the  sternum.  The  flexion  motion  therefore  really  takes  place  long 
before  the  commencement  of  labour,  and  instead  of  being  wholly 
effected,  is  only  a  little  increased  during  labour. 

726.  In  this  way  the  occiput  by  being  depressed  soon  corres^ 
ponds  to  the  centre  of  the  superior  strait ;  the  occipito-bregmatic 
diameter  is  then  parallel  to  the  oblique  diameter,  which  extends 
from  left  to  right  and  from  front  to  rear ;  the  bi-parietal  diameter 
represents  the  other  oblique  diameter  ;  the  occipito-mental  diame- 
ter is  parallel-'to  the  axis  of  the  pelvic  circle,  and  the  occipito-breg- 
matic circumference  corresponds  to  the  plane  of  the  strait. 

727.  Rotation.  In  this  state  the  head  is  disposed  in  the  best  pos- 
sible manner  to  pass  without  difficulty  through  the  upper  strait ;  by 
successive  pains  it  is  forced  to  descend  a  little  ;  it  reaches  the  ex- 
cavation, and  being  soon  stopped  by  the  floor  of  that  cavity,  it 
executes  the  rotation  or  pivot  motion ;  that  is  to  say,  it  turns  upon 
its  great  a.^is,  the  occiput  sliding  upon  the  left  anterior  inclined 
plane,  from  behind  forwards  and  from  left  to  right,  so  as  to  place 
itself  behind  the  symphysis  or  under  the  arch  of  the  pubis,  while  the 
forehead  slides  from  right  to  left  and  from  before  backwards  on  the 
right  posterior  inclined  plane,  so  as  to  get  into  the  hollow  of  the 
sacrum.  This  is  the  moment  when  the  sacral  plexuses  are  most 
forcibly  compressed,  and  when  most  women  are  aflfected  with 
cramps  in  the  legs  and  thighs. 

728.  Extension.  Hitherto  the  flexion  of  the  head  has  gone  on 
increasing  ;  henceforth  it  diminishes ;  the  extension  movement  is 
about  to  begin  ;  as  it  approaches  the  inferior  strait  the  occiput 
rises,  and  by  degrees  causes  the  chin  to  abandon  the  front  of  the 
thorax  ;  instead  of  continuing  to  bend  forwards,  the  head  tends  to 
turn  over  backwards,  in  order  that  the  occipito-mental  diameter 
may  be  brought  into  parallelism  with  the  axis  of  tha  inferior  strait, 
without  hindering  the  rest  of  the  trunk  from  still  following  the  course 
pf  the  central  line  of  the  superior  strait ;  the  rectum  and  neck  of 


PRESENTATION  OF  THE  VERTEX.         293 

the  bladder  being  now  more  forcibly  compressed  than  before,  give 
rise  to  a  straining,  and  tenesmus  ;  the  womb  and  abdominal  muscles 
contract  more  violently  than  ever  ;  the  perineum  distends,  elongates, 
grows  thin,  and  in  this  way  prolongs  the  posterior  wall  of  the  pelvis 
to  an  extent  of  from  three  to  four  inches.  The  head  being  once 
engaged  in  the  inferior  strait,  is  no  longer  in  the  same  relation  to 
the  diameters  as  before.  Yet,  it  is  well  to  observe  that  its  great 
diameter  and  occipito-bregmatic  circumference  have  not  undergone 
any  change  of  this  sort,  and  that  below  as  well  as  above  they  still 
represent  the  plane  and  axis  of  the  strait.  But  instead  of  being 
situated  obliquely,  the  bi-parietal  and  occipito-bregmatic  axes  are 
so  situated,  that  the  former  corresponds  to  the  direction  of  the 
bi-sciatic  diameter,  and  the  latter  to  that  of  the  coccy-pubal  diame- 
ter ;  which  is  the  reason  why  at  the  end  as  well  as  at  the  beginning 
of  labour  the  great  diameters  of  the  occipito-bregmatic  circumfer- 
ence  are  always  found  to  correspond  to  the  largest  diameters  of  the 
pelvis,  and  why  the  chief  end  of  the  rotation  motion  is  to  establish 
these  favourable  relations. 

729.  As  the  rotation  takes  place  only  at  the  expense  of  a  twist 
of  the  child's  neck,  and  not  of  its  whole  body,  the  shoulders  retain 
their  primitive  direction  at  the  superior  strait,  so  that  their  great 
diameter  is  parallel  to  that  oblique  diameter  which  proceeds  from 
left  to  right,  and  from  behind  forwards. 

730.  The  efforts  of  the  woman  are  now  redoubled,  the  head 
gradually  engages  in  the  vulva,  its  back  part  being  forwards,  and 
slides  down  the  plane  presented  by  the  anterior  surface  of  the  coccyx 
and  extended  perineum,  which  plane  is  strongly  inclined  forwards  ; 
the  great  labia  are  slowly  effaced,  and  grow  thin  from  their  perineal 
corhmissure  towards  their  pubal  extremity  ;  the  nympha?  are  forci- 
bly pressed  in  an  upward  and  lateral  direction,  but  they  do  not  un- 
fold ;  they  could  sooner  be  torn  and  separated  from  the  inner  sur- 
face of  the  vulva  ;  sometimes  even  the  skin  of  the  upper  part  of 
the  thighs  yields,  so  as  to  assist  the  pudendum  and  perineum  in 
forming  the  sort  of  casque,  with  which  the  head  remains  partially 
covered  until  it  escapes  entirely  from  the  pelvis  ;  the  parietal  protu- 
berances at  length  pass  through  the  bi-sciatic  diameter,  and  the  head, 
now  arrested  by  the  resistance  of  the  soft  parts  only,  is  soon  com- 
pletely expelled.  Whilst  it  is  passing  through  the  vulva,  the  pos- 
terior end  of  the  occipito-bregmatic  diameter,  continues  to  rest 
under  the  symphysis  pubis,  as  upon  a  transverse  axis,  and  rolls  from 
behind  forwards,  as  the  occiput,  the  sagittal  suture,  the  parietal  pro- 
tuberances, the  anterior  fontanel,  the  frontal  bone,  the  orbits,  the 
nose,  the    mouth   and  chin  are    seen  to    emerge  in   succession. 


294  NATURAL  EUTOCIA. 

When  the  occipito-bregmatic  circumference  is  expelled,  the  anterior 
edge  of  the  perineum,  being  drawn  backwards  by  its  natural  elasti- 
city, slides  over  the  face,  which  affords  it  a  plane  inclined  obliquely 
from  the  forehead  to  the  chin,  and  approaching  near  the  coccyx 
goes  afterwards  to  place  itself  on  the  fore  part  of  the  neck,  forcing 
meanwhile  the  head  to  turn  over  upon  the  mons  veneris. 

731.  Restitution.  The  head,  now  freed  from  all  constraint,  and 
incapable  of  retaining  the  twist  which  had  brought  it  under  the  arch 
of  the  pubis,  soon  recovers  its  natural  relation  to  the  shoulders  and 
rest  of  the  body,  which  had  been  temporarily  changed  ;  that  is  to 
say,  its  antero-posterior  diameter  again  crosses  the  transverse  diame- 
ter of  the  shoulders  at  right  angles,  as  it  did  when  at  the  superior 
strait.  In  one  word,  the  occiput  turns  towards  the  left  groin,  while 
the  chin  is  directed  towards  the  opposite  sub-iliac  space,  and  the 
title  of  act  of  restitution  has  been  given  to  this  rotation. 

732.  After  a  calm  of  a  few  seconds  or  minutes  duration,  the 
shoulders  descend  into  the  excavation,  and  perform  a  pivot  mo- 
tion upon  the  anterior  right  and  posterior  left  inclined  planes  ;  the 
right  shoulder  being  directed  behind  the  symphysis  or  under  the 
pubic  arch,  and  the  left  on  the  front  of  the  sacrum,  forces  the 
head  to  undergo  a  similar  motion,  which  places  it  entirely  cross- 
wise, the  occiput  being  to  the  left  and  the  face  to  the  right.  In 
this  direction  they  engage  in  the  inferior  strait.  The  right  appears 
first  under  the  pubis ;  the  child's  body  bends  on  its  right  side  so  as 
to  accommodate  itself  to  the  pelvis ;  the  left  shoulder  comes  down 
upon  the  perineum  ;  the  vertical  axis  of  the  thorax  is  parallel  with 
the  axis  of  the  perineal  strait ;  the  vertical  axis  of  the  a"bdomen 
represents  that  of  the  superior  strait ;  they  pass  the  vulva  together, 
and  the  rest  of  the  body,  rendered  very  slippery  by  the  liquor  amnii 
and  sebaceous  matter,  and  now  representing  only  the  point  of  a  cone 
whose  base  has  already  escaped,  is  expelled  by  the  power  of  the 
same  effort,  and  the  labour  is  terminated. 

B.  Second  Variety. 
Right  occipito-acetabular  position. 
2d  position  of  Solayres  and  Baudelocque ;  right  antero-Iateral  of  Madame  Boivin ; 
right  occipito-anterior,  Dug^s ;  3682  in  20,517  cases,  Madame  Boivin  ;  4659  in 
22,282  cases,  Madame  Lachapelle. 

733.  Admitting  that  the  situation  might  determine  the  occurrence 
of  the  first  variety,  the  same  cannot  be  said  of  the  second.  M.  Duges, 
it  is  true,  mentions  two  cases,  where,  in  this  last  named  position,  the 
bowel  was  transposed,  being  found  on  the  right  instead  of  the  left 


PRESENTATION  OF  THE  VERTEX.        295 

side  ;  but  anatomical  observations  in  daily  repeated  dissections  show 
that  such  an  anomaly  does  not  occur  once  in  every  three  or  four 
subjects,  as  ought  to  be  the  case  were  it  the  only  or  even  the  prin- 
cipal cause  of  the  position  :  and  besides,  when  it  has  been  met  with, 
was  it  not  rather  an  effect  than  a  cause ;  and  is  it  not  more  rational 
to  attribute  the  second  position  to  the  contractions  of  the  womb 
itself?  If  it  be  true,  for  example,  as  several  facts  carefully  examined 
might  lead  me  to  believe,  that  previously  to  the  commencement  of 
labour,  the  occiput  has  no  determinate  position,  and  does  not  pro- 
perly belong  to  one  anterior  variety  more  than  to  the  other,  may 
we  not  suppose  that  the  uterus,  being  inclined  to  the  right  and  in 
front,  is  more  disposed  to  push  the  head  towards  the  left  than  the 
right  side  of  the  pelvis  ?  The  impulse  received  by  the  foetus  in  this- 
inclination  of  the  womb  is  necessarily  directed  from  right  to  left ;  in 
which  case  the  forehead,  being  arrested  by  the  musculo-vascular 
edge  found  in  the  apex  of  the  triangle  represented  by  the  abdominal 
strait  in  the  living  subject,  must  compel  the  occiput  to  yield  alone 
to  the  movement,  and  go  to  place  itself  opposite  the  left  ilio-pectineal 
eminence.  Without  attaching  any  great  importance  to  this  idea,  I 
should  find  it  an  easy  task  to  advance  a  considerable  number  of 
reasons  in  support  of  it,  and  I  think  it  deserving  of  the  attention  of 
those  practitioners  who  love  to  give  an  account  of  what  they  observe. 

734.  However  it  may  be,  as  to  the  causes  of  the  right  acetabular 
position,  it  is  true  that  its  mechanism  differs  but  little  from  that  of 
the  preceding  one  :  the  child  is  impelled  by  the  same  power  ;  the 
head  executes  the  same  movements,  presents  the  same  circumfe- 
rence in  the  different  planes  of  the  pelvis,  and  offers  the  same  dia- 
meters to  the  principal  diameters  and  axes  of  the  straits,  &.c.  But 
the  occipital  fontanel  is  turned  to  the  right  instead  of  the  left  ;  the 
occipito-bregmatic  diameter,  instead  of  proceeding  from  left  to  right, 
goes  from  right  to  left,  and  takes  the  place  of  the  bi-parietal  diame- 
ter ;  during  the  act  of  rotation  its  extremities  slide  upon  the  right 
anterior,  and  left  posterior  inclined  planes,  to  conduct  the  occiput 
under  the  arch  of  the  pubis,  and  the  forehead  in  front  of  the  sacrum. 

735.  At  the  inferior  strait  and  vulva  there  is  not  the  least  differ- 
ence remaining  betwixt  the  two  positions ;  but  after  the  escape  of 
the  head,  the  occiput  in  its  act  of  restitution  turns  to  the  right  in- 
stead of  inclining  itself  towards  the  left ;  the  left  shoulder,  and  not 
the  right,  comes  under  the  symphysis  pubis,  the  right  side,  and  not 
the  left,  slides  along  the  sacro-perineal  curve  ;  the  face  and  whole 
anterior  surface  of  the  foetus  look  towards  the  inside  of  the  woman's 
left  thigh,  instead  of  turning  towards  the  right ;  but  nothing  of  all 


296  NATURAL  EUTOCIA. 

this  process  changes  the  proportional  relations  of  the  foetal  hea^ 
to  the  maternal  pelvis. 

736.  This  variety  is  considered  as  less  favourable  than  the  other ; 
some  have  said  that  it  renders  the  labour  slower  and  more  fatiguing  ; 
when  the  forehead  is  turned  towards  the  right  sacro-iliac  symphysis 
it  is  separated  from  the  parietes  of  the  pelvis  only  by  fat  and  a  layer 
of  peritoneum,  on  which  it  slides  without  any  difBculty,  while  in  the 
second  position,  the  rectum  shortens  the  opposite  oblique  diameter 
a  little.  When  in  the  first  position,  the  occiput  and  forehead  rest  on 
two  regular  planes,  equally  solid  and  smooth  ;  while  in  the  second, 
the  anterior  part  of  the  head  depresses  the  rectum  from  above  down- 
wards, pushes  it  along  before  it,  and  folds  it  so  as  soon  to  form  a 
kind  of  cushion,  whose  thickness  is  also  increased  by  the  foecal  mat- 
ters contained  within  it ;  it  at  least  follows,  that  the  left  posterior 
surface  of  the  basin  is  too  soft  to  allow  the  head  to  glide  rapidly 
down  into  the  lower  part  of  the  excavation.  The  foetus  might  here, 
to  a  certain  extent,  be  compared  to  a  solid  straight  stick,  one  end 
of  which  is  applied  upon  a  smooth  hard  plane,  as  for  example  a 
plate  of  glass,  or  on  the  other  hand  upon  an  uneven  or  spongy  sur- 
face, such  as  a  woollen  cloth  or  a  mattress.  In  the  former  case, 
the  stick  would  slide  along  without  the  least  obstacle  and  under  the 
slightest  impulse,  while  in  the  latter  it  would  not  slide  at  all,  or  with 
difBculty.  Further,  it  may  be  conceived  that  this  state  of  the  plane, 
on  which  the  forehead  is  obliged  to  descend,  may  in  the  same  way 
interfere  with  the  act  of  rotation  or  the  pivot  motion,  &.c.  All  this 
may  doubtless  be  true,  but  upon  looking  at  the  subject  a  little  closer, 
we  soon  perceive  that  much  is  to  be  retracted  of  these  pretended 
difficulties  ;  for,  1 .  The  thickness  of  the  rectum  when  compressed 
by  the  head  is  reduced  to  a  very  small  degree  ;  2.  The  matters  with 
which  it  is  filled  are  or  may  be  evacuated  at  the  very  beginning  of 
labour ;  and  3.  The  forehead  in  every  case  presses  on  the  rectum, 
through  the  parietes  of  the  womb,  which  does  not  rise  in  folds. 

'  On  this  subject  I  think  I  ought  to  point  out  a  contradiction  found 
in  the  authors  on  midwifery.  On  the  one  hand,  they  say  that  the 
right-acetabular  position  is  determined  by  the  presence  of  the  rec- 
tum on  the  right  side  of  the  sacrum,  and  on  the  other,  that  this  same 
position  is  rendered  less  favourable  by  the  friction  of  the  head  on  the 
bowel  on  the  left. 

Remarks.  The  act  of  rotation  in  these  two  positions  has  Hot  been 
interpreted  in  the  same  way  by  all  authors.  Madame  Boivin  and 
some  others  account  for  it  by  referring  it  to  the  contraction  of  the 
muscles  that  line  tlie  excavation.     But  it  is  evident  that  such  an  ex- 


PRESENTATION  OF  THE  VERTEX.         297 

planation  is  inadmissible  ;  for,  1.  This  rotation  sometimes  takes  place 
when  the  head  is  still  above,  and  most  generally  does  not  occur 
until  it  is  below  the  muscular  bundles,  to  whose  contractions  it  is 
attributed  ;  2.  If  the  pyramidal  and  internal  obturator  muscles,  by 
their  contractions,  could  make  the  head  revolve  on  its  own  axis,  they 
would  carry  it  across  the  pelvis,  and  not  from  front  to  rear.  By 
referring  it  to  the  action  of  the  sterno-mastoid  muscles  of  the  foetus 
itself,  an  opinion  has  been  advanced  still  less  worthy  of  being  com- 
bated than  the  preceding  one. 

Besides,  what  need  is  there  for  us  to  look  for  the  cause  of  this 
movement,  either  to  the  muscles  of  the  pelvis,  or  of  the  child's  neck  ? 
The  occiput  turns  towards  the  pubis,  because  it  finds  a  vacant  space 
there,  while  it  is  strongly  resisted  on  the  sides  ;  it  deviates  from  its 
original  direction  for  the  same  reason  that  the  forehead  turns,  at  the 
superior  strait,  towards  the  sacro-vertebral  angle.  The  form  of  the 
pelvis  and  the  laws  of  mechanics  give  a  perfectly  clear  account  of 
this  peculiarity  :  the  anterior  wall  of  the  excavation,  which  is  much 
shorter  than  the  posterior,  being  deeply  notched  and  somewhat 
hollowed  out,  any  salient  part  of  the  head,  when  strongly  urged  by 
the  contractions  of  the  womb,  could  scarcely  fail  to  engage  in  it,  not 
only  without  the  assistance  of  the  contractions  of  the  inclined  planes, 
but  even  in  spite  of  those  contractions,  were  they  really  to  take 
place. 


C.  Third  Variety.  .7? 

Occipito-pubic  position. 
The  3d  of  Solayres,  Baudelocque,  &c. :  6  in  20,517,  Madame  Boivin. 

737.  The  ancients  regarded  the  occipito-pubic  as  the  most  fre- 
quent position,  because  they  did  not  distinguish  the  two  antero- 
lateral ones,  and  only  judged  from  what  is  observed  at  the  inferior 
strait.  Baudelocque  admitted  it  rather  for  the  purpose  of  filling 
up  his  plan  than  from  the  testimony  of  his  senses.  Since  his  time 
MM.  Gardien,  Dubois,  Flamant,  Dewees,  and  Desornieaux,  as  well 
as  Madame  Boivin,  have  continued  to  describe  it,  at  the  same  time 
admitting  it  to  be  very  rare.  In  fact,  out  of  twenty  thousand  five 
hundred  and  seventeen  children,  six  only  were  found  to  present  in  this 
manner.  MM.  Maygrier,  Capuron  and  Duges  have  argued  against 
the  possibility  of  its  occurrence",  and  Madame  Lachapelle  affirms 
that  she  never  observed  one  single  instance  of  it  in  more  than 
thirty-six  thousand  labours. 

The  question  therefore  is,  whether  it  is  proper  to  retain  it  in  a 
2N 


298  NATURAL  EUTOCIA. 

regular  classification.  The  labours  and  researches  of  the  moderns 
are  almost  the  only  ones  that  can  be  usefully  consulted  for  the  pur- 
pose of  deciding  upon  this  point ;  for  as  Baudelocque  found  no  ob- 
jections that  he  thought  it  worth  while  to  combat,  he  neglected  to  cite 
any  particular  facts  for  the  purpose  of  demonstrating  the  possibihty 
of  its  occurrence.  It  is  objected  by  MM.  Maygrier  and  Capuron, 
that  the  forehead,  being  a  solid  and  round  part,  cannot  maintain  itself 
in  front  of  the  sacro-vertebral  angle  during  the  expulsive  contrac- 
tions of  the  womb  ;  that  two  round  and  equally  salient  bodies  cannot 
slide  upon  each  other  without  turning  off  to  the  right  or  left ;  in  one 
word,  that  previously  to  the  close  of  pregnancy,  or  at  least  at  the 
very  commencement  of  labour,  the  forehead  of  the  foetus  is  neces- 
sarily repelled  by  the  promontory  towards  one  of  the  sacro-iliac 
symphyses. 

738.  Without  denying  the  force  of  these  objections,  I  may,  not- 
standing,  be  permitted  to  observe,  that  in  the  recent  pelvis  the 
sacro-iliac  hollow  is  to  a  great  degree  effaced  by  the  psoas  muscles 
and  iliac  vessels  ;  that  the  vertebral  projection  is  thus  considerably 
diminished  ;  that  the  entrance  to  the  excavation  is  then  not  so  large 
behind  as  it  is  in  front  (72) ;  that  the  womb  being  directed  in  con- 
formity with  the  axis  of  the  superior  strait,  rather  than  with  the  axis 

k  of  the  spine,  and  the  head  of  the  child  habitually  bent  upon  its  breast, 

the  forehead,  at  the  commencement  of  labour,  ought  to  correspond 
to  the  anterior  surface  of  the  first  piece  of  the  sacrum,  and  not  to 
the  sacro-lumbar  projection,  properly  so  called  ;  and  therefore  that 
it  does  not  seem  impossible  for  the  head  to  descend  in  a  direct  posi- 
tion. I  add,  with  M.  Desormeaux,  that  authors  have  reasoned  upon 
this  case  as  if  the  pelvis  were  always  the  same,  always  regular. 
Where  the  vertebral  angle  is  but  slightly  expressed,  or  thrown  back, 
the  sacro-pubic  diameter  is  sometimes  longer  than  common,  without 
the  cavity  of  the  pelvis  being  really  vitiated  ;  in  such  a  case  the  third 
position,  far  from  being  impossible,  should,  on  the  contrary,  be  the 
most  natural  and  the  ea.sicst,  inasmuch  as  the  head,  in  engaging, 

jg  always  strives  to  place  the  great  diameter  of  the  circumference  that 
presents  parallel  to  the  greatest  diameter  of  the  pelvis.  Although 
Madame  Boivin  states  on  the  one  hand  that  she  has  met  with  it  six 
times  in  twenty-five  thousand  five  hundred  and  seventeen  cases,  on 
the  other,  Madame  Lachapelle  aflirms  that  it  is  never  met  with. 
These  contradictory  assertions  at  Jeast  prove  that  the  situation  of 
the  head  at  the  commencement  of  labour  has  not  always  been  recog- 
nized with  certainty  at  the  Paris  Matcrnite.  And  how  could  it  be 
otlierwise  ?  Ry  the  confession  of  all  practitioners,  it  is  very  often 
impossible,  previously  to  the  rupture  of  the  membranes,  to  tell 


PRESENTATION  OF  THE  VERTEX.  299 

whether  the  occipital  fontanel  is  in  front  or  behind,  and  a  fortiori, 
whether  it  is  to  the  right  or  left,  rather  than  in  the  middle  of  the 
strait.  Now,  is  it  probable  that  Mesdames  Boivin  and  Lachapelle 
could,  themselves,  have  touched  each  of  these  thirty-six  thousand 
women  before  the  head  had  engaged  in  the  excavation  ?  To  con- 
clude, although  it  be  true  that  the  occipito-pubic  position,  three  very 
authentic  cases  of  which  are  mentioned  by  Dr  Dewees,  is  of  very 
rare  occurrence,  it  is  not  less  true  that  we  are  not,  in  the  present 
state  of  the  science,  authorised  to  deny  its  possibility ;  and  as  its 
mechanism  is  not  altogether  the  same  as  that  of  the  occipito-aceta- 
bular  positions,  I  think  it  right  to  say  a  few  words  in  regard  to  it. 

739.  When  at  the  superior  strait,  the  occipito-mental  diameter 
and  the  occipito-bregmatic  circumference  are  placed  as  in  the  two 
first  positions,  and  always  correspond  to  the  axis  and  plane  of  that 
opening  :  but  the  bi-parietal  diameter  is  situated  transversely,  and 
the  occipito-bregmatic  from  front  to  rear,  instead  of  being  parallel  to 
the  oblique  diameters  ;  the  pivot  movement  is  not  necessary  and  does 
not  take  place ;  the  direction  of  the  various  axes  of  the  head  is  the 
same  at  the  end  as  at  the  commencement  of  the  labour  ;  as  the  shoul- 
ders look  towards  the  iliac  fossa3  at  the  commencement,  it  is  uncertain 
which  way  the  act  of  restitution  will  take  place  ;  in  fact,  there  will  be 
none,  because  there  was  no  previous  act  of  rotation ;  however,  as  it 
is  a  rare  occurrence  for  the  shoulders  not  to  place  themselves  one  in 
front  and  the  other  behind,  before  they  pass  tiirough  the  inferior 
strait,  the  occiput,  after  a  few  moments  of  indecision,  turns  to  the 
right  or  left,  but  without  our  being  able  to  know  beforehand  which ; 
after  that,  there  is  nothing  peculiar  in  the  rest  of  the  labour. 

740.  Remarks.  It  cannot  be  denied  that  these  three  positions  are 
in  fact  but  shades  of  each  other.  In  all  three  cases  the  head  begins 
by  flexing  itself  strongly  down  upon  the  breast,  and  ends  by  extend- 
ing itself  as  it  passes  out  under  the  arch  of  the  pubis ;  the  occiput,  a 
projecting  part  that  always  comes  out  first,  never  has  more  than  two 
inches,  or  at  most,  two  inches  and  a  half  to  pass  over  before  it 
reaches  the  arch  of  the  pubis,  and  in  escaping  from  the  pelvis,  it 
slides  on  a  surface  that  is  plane  and  even  convex,  but  not  at  all 
concave.  Although  in  the  first  variety  every  thing  is  disposed  in 
the  most  advantageous  manner,  the  presence  on  the  one  hand  of 
the  rectum,  and  on  the  other  of  the  bladder  and  sacro-vertebral 
angle,  cannot,  after  all,  render  the  second  and  third  any  more  difficult 
or  dangerous. 

2.  Ocdpito-Poaterior  Position. 
320  ill  35,895  cases,  Madame  Lachapelle  ;  203  in  20,517,  Madame  Boivin 


300  NATURAL  EUTOCIA. 

741.  Of  far  less  frequent  occurrence  than  the  occipito-anterior 
position,  the  occipito-sacral  position  is  also  much  less  easy,  and  less 
natural.  In  order  to  emerge  first,  the  occiput  is  compelled  to  tra- 
verse the  whole  extent  of  the  anterior  face  of  the  sacrum,  the  coccyx, 
and  perineum,  that  is  to  say,  a  surface  of  from  seven  to  eight  inches 
in  length  ;  while  in  the  other  position  it  escapes  after  passing  over  not 
more  than  two  inches.  The  posterior  wall  of  the  pelvis  is  deeply 
excavated,  while  its  anterior  half  circle  is  rather  convex  than  con- 
cave ;  the  summit  of  the  head  falls  nearly  at  right  angles  upon  each 
point  of  that  wall,  and  the  occiput  meets  a  new  resistance  at  every 
effort ;  which  is  not  the  case  when  it  is  turned  in  front.  The  vertex 
cannot  present  itself  at  the  vulva  until  a  considerable  part  of  the 
breast  has  descended  into  the  excavation  ;  so  that  it  is  no  longer 
merely  the  occipito-bx'egmatic  diameter,  but  it  is  a  line  drawn  from 
the  anterior  fontanel  to  the  posterior  part  of  the  thorax  that  is  re- 
ferred to  the  antero-posterior  diameter  of  the  lower  part  of  the  ex- 
cavation. Here  the  vertebral  column  is  so  strongly  curved  that  it 
cannot  but  lose  a  considerable  part  of  the  force  impressed  upon  it 
by  the  womb,  before  that  power  can  reach  the  head.  The  head 
and  trunk  both  together,  and  not  the  head  alone,  traverse  the  exca- 
vation and  inferior  strait ;  and  finally,  the  forehead  is  commonly  too 
broad  to  fill  up  the  top  of  the  pubic  arch  accurately,  and  the  coccy- 
pubic  diameter  may  on  this  account  lose  as  much  as  half  an  inch  of 
its  length. 

742.  The  causes  that  occasion  the  posterior  position  to  occur  are 
little  understood  ;  it  is  better  frankly  to  avow  our  ignorance  than 
vaguely  to  refer  them  to  this  or  that  shape  of  the  pelvis,  to  the  direc- 
tion, or  disproportioned  dimensions  of  the  womb,  to  certain  habits 
of  the  woman,  to  uncommon  movements  of  the  foetus,  &c.  The 
only  thing  that  can  be  affirmed  about  them  is,  that  it  is  pretty  com- 
mon to  meet  with  them  several  times  in  succession  in  the  same 
woman.  Besides,  this  is  a  question  that  requires  some  careful  re- 
searches before  it  can  be  decided.  Although  the  three  principal 
varieties  of  this  position  differ  only  by  slight  shades  from  each  other, 
I  nevertheless  think,  but  merely  for  the  purpose  of  not  deviating  too 
far  from  generally  adopted  opinions,  that  I  am  bound  to  give  a  suct 
cinct  explanation  of  its  peculiar  mechanism.  i^. 

A.  IHrtt  Variety.  ^ 

Left  fronto-acetabular  position. 

4lh  position  of  Baudelocquc,  Gardien,  Dubois,  Dcsormcaux,  Lcbreton,  Fla- 

mant,  Madame  Boivin:  3d  of  Maygrier,  Capuron,  Dugis,  and  Madame  Lacha- 

pelle ;  109  in  20,517  cases,  Madame  Boivin ;  164  in  22,243  cases,  Madame  La- 

chapelle. 


PRESENTATION  OF  THE  VERTEX.  30 1 

743.  The  left  fronto-acetabular  position  is  the  most  common  of 
the  three  posterior  varieties.  It  unites  all  the  most  favourable  con- 
ditions of  its  species,  and  in  this  respect  it  excels  all  the  others. 
The  back  of  the  fcetus  being  turned  backwards  and  to  the  right,  the 
abdomen  towards  the  front  and  left,  its  left  side  to  the  front  and 
right,  and  its  right  side  behind  and  towards  the  left  side  of  the  womb, 
engages  in  the  superior  strait  in  such  a  way  that  the  occipito-mental, 
bi-parietal,  and  occipito-bregmatic  diameters,  and  occipito-bregmatic 
circumference  are  parallel  with  the  oblique  diameters,  the  plane,  and 
axis  of  that  strait,  respectively,  as  in  the  first  anterior  position. 
There  is  this  difference  however,  that  the  frontal  extremity  of  the 
occipito-bregmatic  axis  occupies  the  place  of  the  sub-occipital  ex- 
tremity, that  the  left  extremity  of  the  bi-parietal  diameter  has 
assumed  that  of  its  right  extremity,  that  the  anterior  fontanel  glides 
behind  the  ilio-pectineal  eminence,  instead  of  descending  before  the 
sacro-iliac  symphysis,  and  that  the  posterior  fontanel,  instead  of 
being  slightly  inclined  in  front  and  towards  the  left,  is,  on  the  con- 
trary, turned  more  or  less  backwards  and  towards  the  right,  which, 
as  is  evident,  does  not  at  all  interfere  with  the  proportional  relations 
of  the  head  and  pelvis,  and  prove,  that  so  far  the  posterior  are  not 
more  unfavourable  than  the  anterior  positions. 

744.  After  the  dilatation  of  the  neck  and  the  rupture  of  the  mem- 
branes, when  the  occipito-bregmatic  circumference  has  passed  the 
superior  strait,  the  head,  meeting  with  a  deep  excavation  behind,  is 
rapidly  urged  to  the  very  bottom  of  the  excavation,  and  at  first  the 
labour  seems  to  progress  more  rapidly  than  in  the  very  opposite 
position ;  but,  from  this  moment,  the  difiiculties  mentioned  above 
become  more  and  more  manifest.  Instead  of  being  gradually  re- 
placed by  the  act  of  extension,  as  in  the  anterior  positions,  the 
flexion  still  continues  to  increase  with  every  pain ;  whilst  the  fore- 
head is  arrested  behind  the  pubis  and  the  occiput  is  abutted  against 
the  front  of  the  sacrum,  the  coccyx  and  perineum,  which  resist  so 
as  to  force  it  to  move  forwards,  the  breast  engages  in  the  excavation, 
slides  in  some  measure  behind  the  face,  opposes  the  turning  of  the 
chin  towards  the  centre  of  the  pelvis,  and  makes  it  very  difficult  for 
the  occipito-mental  axis  to  become  parallel  with  the  central  line  of 
the  inferior  strait,  and  especially  with  the  axis  of  the  vulva.  The 
vertebral  column  being  too  much  curved  loses  a  part  of  the  power 
impressed  upon  it  by  the  womb ;  as  it  presses  upon  the  head  at  an 
angle  which  becomes  more  and  more  acute,  it  cannot  urge  it  on- 
wards with  the  same  degree  of  energy,  even  although  the  same  de- 
gree of  force  might  be  employed. 

The  pivot  movement  takes  place,  nevertheless,  and  the  forehead, 


302  NATURAL  EUTOCIA. 

or  the  bregma^  sliding  along  the  left  anterior  inclined  plane,  comes 
from  left  to  right,  and  from  behind  forwards,  to  place  itself  under 
the  arch  of  the  pubis,  whilst  the  vertex,  or  occiput,  moving  upon  the 
right  posterior  inclined  plane,  proceeds  from  before  backwards  and 
from  right  to  left,  into  the  hollow  of  the  sacrum ;  but  this  rotation 
is  effected  with  some  difficulty,  because  the  forehead  is  too  wide  to 
adapt  itself  accurately  to  the  sub-pubal  notch ;  because,  beneath  the 
superior  strait,  the  lateral  regions  of  the  hinder  half  of  the  pelvis  are 
made  up  of  soft  parts,  which  do  not  repel  the  head  with  sufficient 
force  towards  the  median  line ;  lastly,  because  the  extremities  of  the 
occipito-frontal  diameter  and  its  circumference,  and  not  those  of  the 
occipito-bregmatic,  roll  in  inverse  directions  upon  the  planes  of  the 
excavation,  as  is  the  case  in  the  occipito-anterior  position. 

745.  Notwithstanding  so  many  unfavourable  circumstances,  the 
occiput  descends,  by  bearing  strongly  upon  the  sacrum,  the  coccyx, 
and  perineum,  and  the  foetus  finally  passes  the  strait.  In  this  situa- 
tion it  is  upon  the  posterior  commissure  of  the  vulva,  and  not  upon 
the  inferior  edge  of  the  symphysis  pubis,  that  the  occipito-bregmatic 
diameter  now  presses,  slides,  and  reverses  itself  from  above  down- 
wards and  from  before  backwards ;  so  that  the  posterior  fontanel, 
the  sagittal  suture,  the  anterior  fontanel,  the  parietal  protuberances, 
the  frontal  protuberances,  and  the  several  parts  of  the  face,  are  seen 
to  appear  in  succession  in  front  of  the  perineum.  As  soon  as  the 
chin  is  disengaged  from  the  summit  of  the  pubic  arch,  the  act  of 
restitution  takes  place  ;  the  face  inclines  towards  the  left  groin,  and 
the  occiput  towards  the  right  sub-ischiatic  notch  ;  the  left  shoulder 
proceeds  in  front,  under  the  symphysis  ;  the  right  shoulder  reaches 
the  concave  surface  of  the  sacrum  ;  the  head,  governed  by  the 
movement  of  the  trunk,  places  itself  crosswise ;  and  the  rest  of  the 
labour  is  concluded  as  it  is  in  the  right  occipito-acetabular  position. 

B,  Second  Variety. 
Right  fronto-acctabular  position. 
5th  position  of  Baudelocque,  Gardien,  Dubois,  Dcsorincaux,  Madame  Boivin, 
8ic. ;  4th  of  Maygrier,  Capuron,  Duges,  Madame  Lachapelle,  &c. :  92  in  20,517 
cases,  Madame  Boivin  ;  66  in  22,243  cases,  Madame  Lachapelle. 

74G.  The  right  fronto-acctabular  position,  ftlthough  rather  more 
rare  than  the  preceding  one,  is,  notwithstanding,  more  common,  re- 
latively to  the  opposite  fronto-acetabular  position,  than  the  right 
occipito-acetabular  is  when  compared  to  the  left  occipito-acetabular 
position.  Tliis  peculiarity  comes  in  support  of  the  opinion  I  ad- 
v«Accd  when  detailing  the  causes  of  the  first  position  of  the  vertex : 


PRESENTATION  OF  THE  VERTEX.  303 

it  may  in  fact  be  conceived,  that  if  once  placed  behind,  at  the  supe- 
rior strait,  the  occiput  may  descend  almost  indifferently  to  the  right 
or  left  of  the  median  line,  while,  if  turned  forwards,  it  must  be  most 
frequently  repelled  towards  the  left  side. 

In  this  position  the  back  of  the  foetus  is  directed  to  the  left  and 
backwards,  the  right  shoulder  to  the  left  and  forwards ;  the  bi- 
parietal  diameter  represents  the  left  antero-oblique  diameter ;  the 
occipito-bregmatic  is  parallel  with  the  right  antero-oblique  ;  and  the 
lesser  circumference  and  occipito-mental  diameter  are  parallel  with 
the  plane  and  axis  of  the  strait.  The  head,  when  engaged  in  the 
excavation,  revolves  a  half  quarter  of  a  circle  upon  its  vertical  axis. 
The  occiput,  sliding  upon  the  left  posterior  inclined  plane,  proceeds 
to  lodge  in  the  hollow  of  the  sacrum  ;  while  the  bregma,  rolling 
upon  the  right  anterior  inclined  plane,  is  directed  to  the  symphysis 
pubis. 

Upon  emerging  from  the  vulva,  when  the  act  of  restitution  takes 
place,  the  occiput  gradually  turns  towards  the  inside  of  the  left  thigh, 
and  not  the  right,  as  in  the  fourth  position.  As  to  the  rest  of  the 
labour,  it  is  terminated  like  the  former,  except  that  the  front  of  the 
foetus  at  last  looks  towards  the  right,  and  its  right  side  directly  in 
front,  whereas  in  the  other  variety,  directly  the  reverse  is  observed. 
Moreover,  it  is  said  to  be  rather  more  difficult,  in  consequence  of 
the  presence  of  the  rectum,  which  must  retard  the  progress  of  the 
occiput. 

747.  M.  Naegele  maintains  that  the  fourth  position  of  the  vertex 
is  much  more  common  than  the  second,  and  that  the  French  ac- 
coucheurs did  not  perceive  it,  because,  being  led  away  by  the  autho- 
rity of  Baudelocque,  they  did  not  perceive  that  the  former  of  these 
two  positions  commonly  converts  itself  into  the  right  occipito- 
acetabular  position,  as  soon  as  the  head  gets  through  the  superior 
strait.  These  assertions  of  the  German  professor  ought  to  be  taken 
into  consideration,  not  that  they  are  perfectly  correct,  for  even 
provided  the  very  numerous  observations  collected  at  the  Paris  Ma- 
ternite  could  not  be  cited  as  proofs  of  the  contrary,  the  form  of  the 
pelvis  and  the  specific  gravity  of  the  foetus  would  alone  prevent  the 
admission  of  such  an  opinion,  until  its  correctness  had  been  irrever- 
sibly demonstrated  by  multiplied  facts ;  but  they  should  be  taken  into 
consideration,  because  it  appears  certain,  that  when  the  occiput 
reaches  the  bottom  of  the  excavation,  it  does,  in  fact,  in  some  in- 
stances turn  towards  the  acetabulum  instead  of  proceeding  towards 
the  posterior  median  line.  1  have  already  observed  and  pointed  out 
to  many  students  the  reality  of  this  phenomenon,  so  as  to  leave  no 
doubt  upon  the  subject.     Upon  passing  the  pelvic  circle,  the  head 


304  NATURAL  EUTOCIA, 

by  degrees  inclines  to  one  side,  and  places  itself  exactly  cross-wise, 
soon  after  it  descends  into  the  excavation.  This  pivot  motion  con- 
tinues, under  the  influence  of  the  uterine  contractions ;  if  it  be  the 
fourth  position,  the  posterior  fontanel  gradually  reaches  the  arch  of  the 
pubis,  by  ghding  from  behind  forwards,  and  from  right  to  left,  along 
the  right  anterior  inclined  plane,  and  on  the  other  hand  from  left  to 
right  for  the  fifth,  &c. 

748.  I  am  ignorant  of  the  causes  to  which  such  anomalies  ought 
to  be  attributed  ;  I  have  never  found  any  thing  peculiar  in  the  con- 
formation of  those  women  who  have  exhibited  them  ;  the  labours 
have  progressed  regularly,  and  there  was  nothing  unusual  in  the 
weight  of  the  children  ;  I  think  I  have  only  noticed  that  from  the 
very  beginning  of  the  labour,  the  antero-posterior  diameter  of  the 
head  was  much  nearer  to  the  bis-iliac  than  to  the  sacro-pubic  line 
of  the  strait,  and  that  the  pubis,  being  slightly  depressed  above, 
seemed  to  favour  the  anterior  rotation,  by  the  hoUowness  of  the 
arch,  and  by  the  distance  to  which  the  acetabula  were  separated. 

749.  The  knowledge  of  these  conversions  ought  not  to  be  over- 
looked in  practice  :  in  the  first  place,  because,  as  they  are  favoura- 
ble, we  may  in  some  instances  be  enabled  to  promote,  and  even  to 
enforce  them  whenever  such  a  thing  is  possible  ;  in  the  next  place, 
because  they  aflJbrd  a  very  natural  explanation  of  the  mistakes, 
which  we  have  been  heretofore  compelled  to  attribute  to  the  ignor- 
ance of  those  who  committed  them.  For  example,  it  pretty  often 
happens  that  two  accoucheurs,  called  to  the  same  woman,  one  at 
the  commencement  of  the  labour  and  the  other  at  its  close,  an- 
nounce, each,  a  different  position  ;  that  one  announces  an  occipito- 
anterior, and  the  other  the  contrary  position,  and  that  upon  seeing 
the  head  emerge,  one  of  them  remains  convinced  that  he  had  been 
really  deceived.  Notwithstanding,  both  of  them  may  have  been 
right,  for  tlie  fourth  or  fifth  position  might  really  have  existed,  al- 
though the  labour  terminated  in  the  second  or  first.  It  would  be 
wrong,  however,  to  generalise  this  remark  too  far,  and  apply  it  to 
all  cases  where  the  escape  of  the  fcctus  contradicts  the  diagnosis 
established  by  the  practitioner  from  whom  the  woman  first  receives 
attention  :  it  would  be  too  convenient  a  resource  for  the  conceal- 
ment of  real  mistakes,  and  one  of  which  the  inept  and  ill  taught 
would  not  fail  to  avail  themselves  at  the  expense  of  truth. 

C.  Thiyd  Variety. 
Fronto -pubic  position. 
6lh  po8i(ion  of  Baudclocciuc,  MM.  Gardien,  Dubois,  Dcsormeaux,  Madame 
Boivif    .-'•.  M.i.,.  _  .,  .1  .f  i^jii^j  Flamant,  Lebreton;  is  rejected  by  MM.  Maygrici, 
Capi  Ho,  and  M.  Dugis. 


PRESENTATION  OF  THE  VERTEX.  305 

760.  All  the  arguments  advanced  by  authors  against  the  possibility 
of  Baudelocque's  third  position  apply  equally  well  to  the  sixth.  If 
the  forehead  cannot  maintain  itself  upon  the  sacro-vertebral  angle, 
it  is,  a  fortiori,  impossible  for  the  occiput,  which  is  much  narrower, 
to  maintain  itself  in  that  situation  and  not  to  deviate  either  to  the 
right  or  left.  But  as  the  impossibility  of  the  occurrence  of  the 
occipito-pubic  position  is  far  from  being  a  matter  of  demonstration, 
so  also  is  the  same  thing  to  be  admitted  .as  regards  the  opposite 
position. 

Sometimes  the  sacro-vertebral  angle,  in  the  living  subject,  pro- 
jects but  very  slightly,  a  fact  to  which  sufficient  attention  has  not 
been  paid,  and  it  is  evidently  wrong  to  reason  as  if  the  head  were 
not  already  flexed  upon  the  breast  from  the  very  beginning  of  la- 
bour, and  as  if  it  were  the  occipito-frontal,  and  not  the  occipito- 
bregmatic  diameter,  that  is  at  the  very  commencement  parallel  to 
the  antero-posterior  diameter  of  the  strait. 

751.*  If  it  be  true,  as  we  learn  by  the  touch  at  our  amphitheatres, 
that,  in  many  women,  we  can  readily  feel  the  most  prominent  part 
of  the  foetal  head  over  the  centre  of  the  pelvis,  quite  above  its  abdo- 
minal opening,  long  before  the  commencement  of  labour,  I  cannot 
perceive  how  the  sacro-vertebral  angle  can  constitute  an  insurmoun- 
table obstacle  to  the  sixth  position.  It  must  therefore  be  admitted, 
at  least,  as  a  possible  shade,  if  not  as  a  rpal  variety. 

752.  Its  mechanism,  moreover,  scarcely  differs  from  that  of  the 
two  oblique  varieties ;  the  posterior  surface  and  occiput  of  the 
foetus  being,  from  the  beginning,  turned  directly  backwards,  there 
is  no  occasion  for  the  head  to  perform  its  pivot  movement  in  the 
excavation,  so  as  to  engage  in  the  inferior  strait ;  the  shoulders  pass 
through  the  superior  strait  parallel  to  the  bis-iliac  diameter,  and 
there  is  no  act  of  restitution  without,  any  more  than  there  is  an  act  of 
rotation  within  the  pelvis,  and  if  the  face  comes  at  last  to  turn 
towards  one  of  the  thighs  and  the  occiput  towards  the  other,  it  hap- 
pens so  because  the  trunk,  in  revolving  on  its  vertical  axis  to  place 
the  shoulders  in  an  antero-posterior  attitude,  necessarily  carries  the 
bi-parietal  diameter  in  the  same  direction. 

It  is  less  favourable  than  the  corresponding  oblique  positions,  only 
because  it  renders  the  forehead  and  face  more  liable  to  be  turned 
downwards,  and  to  permit  the  great  diameters  of  the  head  to  become 
parallel  to  the  smallest  ones  of  the  pelvis.  When  they  attributed 
the  difficulties  accompanying  it  to  the  friction  of  the  face  behind 
the  pubis,  accoucheurs  of  past  ages,  doubtless,  had  not  reflected 
on  the  state  of  flexion  in  which  the  head  is  fonnd  to  be  placed  ;  for 
2  O 


306  NATURAL  EUTOCIA. 

it  would  have  been  easy  for  them  to  see  that  it  is  the  anterior  ex- 
tremity of  the  occipito-bregmatic  diameter,  and  not  that  of  the  occi- 
pito-frontal  diameter,  that  must  rest  upon  the  hinder  part  of  tiie 
pubic  articulation. 

763.  Remarks.  Besides  these  six  varieties,  there  would  be  a  great 
many  intermediate  ones,  provided  the  occiput  were  obhged,  in 
each  of  them,  to  correspond  to  some  indicated  point  of  the  pelvic 
circle  :  in  effect,  if  there  be  some  of  them  that  we  can  bring  in  re- 
lation with  the  extremities  of  the  four  principal  diameters  of  the 
strait,  [  cannot  perceive  why  eight  others  might  not  be  established 
betwixt  those  just  now  mentioned  ;  and  this  number  once  agreed 
upon,  there  is  no  reason  why  we  might  not  add  sixteen  others,  and 
so  on  ad  infinitum.  But  it  is  quite  enough  to  make  a  particular 
position  of  all  the  cases  where  the  occiput  looks  towards  any  por- 
tion of  the  left  anterior  quarter-circle  of  the  pelvis,  another  for  the 
right,  and  a  third  and  fourth  for  the  posterior  half  of  the  pelvis ; 
since  these  varieties,  which  differ  more  in  degree  than  reality,  ought, 
after  all,  to  be  considered  as  mere  shades,  constantly  changing,  be- 
fore the  close  of  labour,  into  occipito-anterior,  and  occipito-posterior 
positions:  so  that,  in  fact,  the  four  diagonal  positions  of  the  su- 
perior strait,  when  reduced  to  the .  two  antero-posterior  ones  of  the 
inferior  strait,  constitute  the  whole  of  those,  the  study  of  which  is 
really  important.  We  are  not,  however,  on  this  account  to  deny 
the  existence  of  the  directly  anterior  and  transverse  positions  estab- 
lished by  Baudelocque,  M.  Flamant,  and  Madame  Lachapelle. 

754.  I  have  treated  in  greater  detail  of  the  occipito-pubic  and 
sacral  positions  than  of  the  occipito-iliac  positions,  because  their 
mechanism  presents  some  peculiarities  which  it  is  well  not  to  be 
ignorant  of,  for,  the  doctrine  of  Baudelocque  being  extensively 
known,  it  might  be  attended  with  some  inconvenience,  were  I  to 
overlook  positions  admitted  by  that  author  to  exist,  which,  though 
they. are  of  rare  occurrence,  yet  really  do  occur,  and  substitute 
for  them  others  equally  rare,  and  which,  moreover,  soon  become 
confounded  with  the  oblique  ones. 

765.  When  Madame  Lachapelle  says  that  the  occipito-iliac  are 
more  frequently  to  be  met  with  than  the  fronto-acetabular  positions, 
she  must  surely  be  misled  by  some  preconceived  idea.  Previously 
to  the  descent  of  the  head  into  the  excavation,  it  is  often  difficult 
to  say  whether  the  occiput  looks  exactly  towards  one  of  the  ex- 
tremities of  the  transverse  diameter,  rather  than  a  few  lines  for- 
wards or  backwards  of  it,  or  to  know  whether  it  constitutes  a  trans- 
versal position,  rather  than  an  oblique  one  very  much  inclined  : 


PRESENTATION  OF  THE  VERTEX.  307 

further,  as  the  author  herself  admits  tli^t  the  head  remains  but  a 
short  time  thus  directed  towards  the  iliac  fossaa,  either  the  occiput 
or  forehead  soon  deviating  in  front  to  gain  the  pubic  arch,  and  the 
left  occipito-iliac  position  being  the  most  common  of  the  two,  it  is 
manifest  that  the  transverse  positions  are  completely  converted  into 
the  corresponding  oblique  ones,  and  that  they  do  not  deserve  a  par- 
ticular description. 

756.  Anomalies.  In  some  positions  of  the  vertex  the  movements 
of  the  head  seem  to  deviate  wholly  from  the  ordinary  march  of  a 
labour  ;  for  example,  it  may  happen,  and  indeed  it  does  happen 
pretty  often,  that  after  having  passed  obliquely  through  the  superior 
strait,  it  places  itself  transversely  in  the  excavation,  where  it  re- 
mains for  a  longer  or  shorter  time  previously  to  performing  its  pivot 
motion  ;  in  other  cases  this  motion  is  not  performed  at  all,  or  but 
imperfectly  ;  the  head,  therefore,  passes  the  inferior  as  it  did  the 
superior  strait  diagonally,  or  even  emerges  from  it  in  a  transverse 
position,  so  as  to  bring  the  occipito-bregmatic,  into  parellelism  with 
the  bi-sciatic  diameter.  In  some  other  instances,  the  occiput  upon 
escaping  from  the  vulva  turns  in  a  direction  directly  contrary  to  that 
it  ought  to  pursue,  provided  the  restitution  were  regular  ;  it  was  in 
this  way  that  Solayres  and  Baudelocque  saw,  and  that  I  myself  have 
seen,  the  face,  in  a  left  occipito-acetabular  position,  turn  towards  the 
woman's  left  thigh,  as  it  ought  to  do  in  the  second  position,  and 
vice  versa  ;  so  that  from  the  commencement  to  the  close  of  labour, 
the  foetus  performs  about  half  a  spiral  turn,. from  behind  forwards, 
and  from  left  to  right,  or  from  right  to  left,  according  to  the  posi- 
tion. Baudelocque  was  mistaken  when  he  attributed  this  irregu- 
larity, on  the  one  hand,  to  the  smallness  of  the  fcetal  head,  or  on  the 
other  to  the  excessive  amplitude  of  the  pelvis  ;  I  have  had  occasion 
to  notice  it  in  women  whose  labours  were  very  slow,  and  whose 
pelves  were  not  larger  than  necessary  for  the  transmissioi»of  the 
child.  Might  it  not  depend  upon  some  peculiarity  in  thjg  form  of 
the  inferior  strait  or  excavation,  some  anomaly  in  the  uterine  con- 
tractions, or  rather  of  the  impulsion  originally  communicated  to  the 
foetus ;  and  which,  after  having  first  produced  the  common  act  of 
rotation,  might  be  strong  enough  to  compel  the  head  and  shoulders 
to  turn  so  as  to  perform  a  complete  semi-circular  turn  ?  In  the 
present  state  of  tokological  science  it  is  impossible  to  answer  this  ' 
question. 

§.  II.  Presentation  of  the  face. 

4  in  1800  cases,  Merriman  ;  5  in  1897,  Bland  ;  74  in  20,517,  Boivin  ;  103  jn 
22,243,  Madame  Lachapslle  ;  58  in  6,555,  Boer. 


308  NATURAL  EUTOCIA. 

757.  It  never  until  lately  entered  any  one's  imagination  to  trust 
the  delivery  to  the  hands  ofnature,  where  the  face  of  the  child  pre- 
sented at  the  superior  strait  of  the  pelvis  ;  it  is  true  we  find  in  Mau- 
riceau,  De  La  Motte,  and  Smellie,  cases  of  spontaneous  termination 
of  the  labour  where  the  face  presented  ;  P.  Portal  and  Deleurye  also 
maintained  that  these  positions  are  not  in  general  very  dangerous  ; 
Roederer  and  Petit  even  awree  that  some  of  them  may  terminate 
without  any  assistance  ;  but  Baudelocqueand  Stein  having  professed 
that  they  cannot  possibly  terminate  spontaneously  except  where  the 
foetus  is  very  small  or  the  pelvis  very  large,  it  has  happened  that 
MM.  Maygrier,  Gardien,  Capuron,  &c.  continue  to  class  them 
among  the  preternatural  labours. 

758.  Such  was  the  state  of  the  subject  when  Madame  Lachapelle 
laid  it  down  as  a  principle,  that  this  sort  of  labour  is  nearly  as  easy 
and  as  natural  as  that  by  the  vertex,  and  affirmed,  that  out  of  seventy- 
two  cases  of  this  kind,  forty-two  were  concluded  without  danger 
either  to  the  mother  or  child.  M.  Desormeaux  ranged  himself  on 
the  side  of  the  midwife  in  chief  of  the  Maternite;  and  the  same  ideas 
are  found  in  the  work  of  Boer,  who,  after  saying  that  delivery  by  the 
face  is  very  simple  and  very  natural,  describes  its  mechanism  in  the 
following  manner :  Caput  fiBtas,  ex  quo  supra  in  margine  pubis 
?uBret,  per  illam  ita  transmovetur,  ut  frons  sensim  in  incurvaturam 
ossis  sacri  vergat.  Utque  fades  aperturce  infra  appropinquate 
mentum  propemodo  admittitur  sub  pube,  simul  atque  frons  cum  ver- 
tice  supra  perincBum  protruditur.  En  facialis  omnis  partfis  exor- 
dium, progressus  ac  finis ! 

M.  Chevreul  expresses  himself  in  nearly  the  same  manner  :  "  / 
can  enumerate  eighteen  labours,  says  he,  that  occurred  since  1792, 
either  in  my  private  practice,  or  at  the  Maternite  at  Angers,  where 
the  children  presented  the  face,  and  which  terminated  naturally.  All 
these  chj/dren  were  of  the  common  size ;  fifteen  of  them  were  bom 
alive ;  three  were  dead,  but  appeared  to  have  been  so  previously  to 
the  commencement  of  labour." 

However,  a  distinguished  professor,  M.  Capuron,  has  recently 
come  out  with  great  vigour  in  opposition  to  this  doctrine,  endeavour- 
ing to  demonstrate  upon  geometrical  principles,  that  delivery  by  the 
face,  according  (o  the  mechanism  pointed  out  by  Boer,  is  generally 
•impossible,  provided  the  woman  does  not  receive  any  artificial  aid. 
But  no  geometry  can  hold  good  in  this  case;  as  numerous  facts 
exist,  they  are  evidently  possible.  I  have  myself  seen  seven  cases 
of  face  presentation  ;  the  children  were  born  alive  and  well ;  I  trusted 
thp  cases  to  nature,  and  no  particular  difficulties  were  observable. 

This  kind  of  labour,  therefore,  is  not  only  possible,  but  also  for 


PRESENTATION  OF  THE  FACE.  309 

the  most  part  quite  easy.  M.  Capuron  and  many  others  have  thought 
otherwise,  because  they  did  not  perfectly  understand  its  mechanism, 
and  were  misled  by  the  idea  that  the  breast  in  such  cases  must  ne- 
cessarily pass  the  strait  at  the  same  time  with  the  head,  which  is 
wholly  incorrect.  It  is  clear,  when  the  head  presents  at  the  superior 
strait,  with  the  chin  towards  the  pubis  and  the  forehead  towards  the 
sacrum,  that  the  fronto-mental  diameter,  which  is  only  three  inches, 
or  if  prolonged  to  the  anterior  fontand,  three  inches  and  a  half,  is 
parallel  with  the  sacro-pubic  diameter,  equal  to  four  inches  and  a 
half,  and  that  it  occupies  the  situation  that  belongs,  in  vertex  pre- 
sentations, to  one  of  the  diameters  of  the  occipito-bregmatic  circum- 
ference. So  far  there  is  no  disadvantage  in  a  face  presentation. 
But  at  a  later  period,  when  the  head  descends,  the  chin  gets  below 
the  pubis  before  the  occiput  reaches  the  excavation,  and  the  breast 
is  still  at  the  superior  strait  while  the  face  is  actually  engaging  in 
the  inferior  pelvic  circle ;  then,  the  front  of  the  neck,  being  stopped 
by  the  lower  edge  of  the  symphysis  pubis,  compels  the  vertebral 
column  4o  react  upon  the  posterior  part  of  the  head,  which  it  urges 
from  behind  forwards,  so  as  to  force  it  through  the  vulva,  by  pre- 
senting to  that  opening  a  series  of  circles,  whose  principal  chords  are 
measured  by  the  vertical  diameter  of  the  head.  The  laws  of  me- 
chanics, therefore,  in  accordance  with  facts,  permit  us  to  class  face 
cases  among  the  spontaneous  labours. 

759.  According  to  Deventer,  the  causes  of  this  presentation  are 
to  be  sought  for  in  the  obliquities  of  the  uterus,  which,  from  the  very 
beginning  of  its  action,  cause  the  extremity  of  the  occiput  to  lodge 
upon  the  margin  of  the  strait,  and  thus  oblige  the  face  to  descend 
first.  According  to  M.  Gardien,  the  cause  lies  much  more  in  the 
inclination  or  obliquity  of  the  fffitus  itself,  than  in  that  of  the  organ 
which  contains  it.  Madame  Lachapelle,  who  rejects  both  of  these 
hypotheses  because  she  saw  the  face  presenting  at  the  upper  strait 
in  two  women  who  died  previously  to  labour,  attributes  it  to  the  cir- 
cumstance that  the  anterior  obliquity  of  the  womb  being  very  com- 
mon, the  weight  of  the  occiput  must  in  such  cases  prevent  the  chin 
from  remaining  applied  against  the  sternum,  and.  must  bring  the 
raento-bregmatic  diameter  into  parallelism  with  the  sacro-pubic 
diameter  from  the  very  commencement  of  labour.  It  seems  to  me 
that  all  these  opinions  have  some  foundation,  but  that  none  of  them 
suffice  to  explain  all  the  facts,  and  that  it  is  for  the  most  part  impos- 
sible to  say  wliy  the  face  and  not  the  occiput  presents. 

760.  The  face  positions  being  in  fact  only  reverted  vertex  posi- 
tions, it  is  plain  that  We  must  for  both  admit  the  same  number  of 
species  and  varieties.     Authors,  however,  have  generally  described 


310  NATURAL  EUTOCIA. 

only  four ;  and  they  have  rarely  agreed  as  to  the  manner  of  arrang- 
ing them.  Some  make  them  correspond  to  the  four  oblique  posi- 
tions of  the  vertex  ;  others,  as  Smellie,  Stein,  Baudelocque,  and 
MM.  Gardien  and  Desormeaux,  dispose  them  transversely,  and  from 
front  to  rear,  and  admit  a  right  mento-iliac  and  a  left  mento-iliac 
position,  as  well  as  a  mento-puhic,  and  a  mento-sacral  position. 

Perhaps,  in  studying  the  subject,  there  is  some  advantage  in  this 
latter  mode  of  classifying  them  ;  but  it  is  important  in  practice  to 
know,  1.  That  the  antero-posterior  positions  are  rare,  so  much  so, 
that  Madame  Lachapelle  has  never  seen  a  single  case  of  that  kind, 
although  Roederer,  Deleurye,  Stein,  &c.  admitted  them  as  very 
common,  and  as  the  easiest ;  2.  That  if  tliey  do  sometimes  occur  at 
the  commencement,  as  in  one  case  that  I  saw,  they  soon  become 
converted  into  lateral  positions  ;  3.  That  the  mento-sacral  position, 
which  Stein  gives  as  the  best,  and  of  which  one  case  is  related  by 
Smellie,  is  altogether  impossible  without  this  conversion  ;  and, 
4.  That  in  the  iliac  positions,  the  fronto-mental  diameter  is  more 
frequently  directed  obliquely  than  transversely. 

761.  It  ought  also  to  be  known  that  the  face  does  not  always 
present  in  full ;  that  the  forehead  often  sinks  lower  than  the  chin  ; 
that  the  contrary  obtains  in  other  cases ;  that  in  some  instances, 
also,  it  descends  with  one  of  the  cheeks  foremost,  &c.,  and  that 
these  anomalies  constitute  the  varieties  pointed  out  by  Madame  La- 
chapelle ;  and  which  may  be  either  primitive,  that  is,  they  may  exist 
from  the  very  commencement  of  labour,  or  secondary,  that  is,  not 
become  manifest  until  after  the  first  efforts,  and  even  at  a  very  ad- 
vanced stage  of  parturition  ;  and  that  the  last  case  ought  to  be  con- 
sidered as  possible,  for  example,  in  vertex  presentations  with  the 
occiput  backwards,  or  where  the  pelvis  is  very  large,  and  also  where 
the  sacrum  is  too  concave. 

A.  Right  Mento-iliac  Position. 
Sd  of  Baudelocque,  M.  Gardien,  Madame  Boivin;  53  cases  in  22,243,  Madame 
Lachapelle. 

762.  In  the  right  mento-iliac  position,  which  evidently  is  a  devia- 
tion of  the  first  or  fifth  of  the  vertex,  and  ought  therefore  to  be,  and  in 
fact  is  the  most  common  (41  to  31  ;  58  to  45),  the  face  comes  down 
transversely  into  the  excavation ;  but  as  the  longtii  of  the  neck  would 
not  allow  the  chin  to  get  down  to  the  level  of  the  tuberosity  of  the 
ischium  without  dragging  the  upper  part  of  the  thorax  through  the 
superior  strait,  without  throwing  the  occiput  forcibly  backwards  on 
to  the  chest,  without  putting  the  whole  lengtli  of  the  vertical  diame- 
ter of  the  head,  protracted  as  far  as  the  sternum,  into  the  situation 


PRESENTATION  OF  THE  FACE.  311 

that  ought  to  be  occupied  by  the  fronto-mental  diameter,  a  rotative 
movement  soon  takes  place,  and  changes  the  relations  of  all  these 
parts :  the  chin  and  front  of  the  neck  slide  from  behind  forwards  upon 
the  right  anterior  inclined  plane,  and  lodge  in  the  top  of  the  arch  of 
the  pubis,  while  the  bregma  slides  in  an  opposite  direction,  upon  the 
left  posterior  inclined  plane,  and  proceeds  to  occupy  the  anterior 
surface  of  the  sacrum.  Then  the  forehead,  followed  by  the  sagittal 
suture  and  occiput,  passes  gradually  down  the  plane  presented  to  it 
by  the  anterior  surface  of  the  coccyx  and  perineum,  in  front  of  which 
all  these  parts  are  in  succession  disengaged.  As  it  emerges  from 
the  vulva,  the  chin  rises,  by  degrees,  towards  the  mons  veneris,  the 
hyoidian  region,  or  lower  extremity  of  the  vertical  diameter,  really 
forms  the  centre  of  the  semicircle  described  by  the  head  as  it  clears 
the  strait,  and  the  rest  of  the  labour  terminates  as  in  the  correspond- 
ing positions  of  the  vertex. 

B.  Left  Mento-Iliac  Position. 
4th  of  Baudelocque ;  M.  Gardien,  Mesdames  Boivin,  Lachapelle,  etc. ;  31  to 
41;  45  to  53. 

763.  Where  the  chin  looks  towards  the  left  iliac  fossa,  the  position 
of  the  face  answers  to  the  second  or  fourth  of  the  vertex.  It  is  rather 
more  frequently  met  with  than  the  preceding  one,  but  does  not 
differ  from  it  except  that  the  chin  slides  on  the  left  anterior  in- 
clined plane,  and  the  bregma  on  the  right  posterior  one,  so  as  to 
place  the  head  in  an  antero-posterior  direction,  in  order  to  pass  the 
perineal  strait ;  and  that  the  act  of  rotation  must  be  somewhat  easier, 
if,  as  is  asserted,  it  be  true  that  the  presence  of  the  rectum  may  im- 
pede that  of  the  right  occipito  and  fronto-acetabular  positions  of  the 
vertex.  *■ 

It  is  said  that  the  head  has  been,  but  very  rarely,  seen  to  emerge 
from  the  vulva  in  a  diagonal  or  even  transverse  position ;  but  it  does 
not  appear  to  me  certain,  that,  in  these  cases,  the  observers  were 
not  deceived  by  an  incipient  act  of  restitution. 

C.  Jtlento- Sacral  Position. 
1st  of  Baudelocque. 

764.  The  third  position  is  extremely  rare,  1.  Because  the  occipito- 
pubic  position,  which  must  give  rise  to  it,  is  itself  not  very  common  ; 
2.  Because  if  it  be  true  that  it  does  sometimes  or  even  pretty  often 
exist  at  the  very  beginning  of  labour,  the  contractions  of  the  womb 
soon  transform  it  into  a  diagonal  or  transverse  position;  3.  Be- 
cause, if  it  should  maintain  itself  for  any  length  of  time,  the  chin, 
which  is  too  prominent  not  to  lodge  against  the  sacro-vertebral 


314  UNNATURAL  EUTOCIA. 

the  action  of  the  heart,  cannot  but  be  very  much  impeded ,  if  not  ab- 
solutely suspended.  In  delivery  by  the  head,  the  spine  represents  a  long 
handle  of  a  lever,  to  which  the  womb  applies  itself  forcibly,  until 
the  termination  of  the  labour  ;  in  presentations  of  the  pelvic  ex- 
tremity, before  the  head  has  completely  passed  through  the  superior 
strait,  it  is  in  a  great  measure  beyond  the  influence  of  the  uterine  con- 
tractions ;  at  the  very  moment  where  the  greatest  amount  of  uterine 
power  is  wanted,  all  the  benefits  of  it  are  lost.  Finally,  the  pressure 
sustained  by  the  parts,  in  succession,  from  below  upwards,  necessarily 
di:ives  the  blood  up  towards  the  head,  and  determines  that  state  of 
congestion  so  often  met  with  in  children  that  are  delivered  footling, 
and  which  Osiander  and  M.  Flamant  erroneously  attributed  to  the 
action  of  cold  air  upon  the  child's  body  previously  to  the  delivery  of 
its  head. 

These  disadvantages  cannot  be  denied,  or  unknown  by  any  well 
informed  practitioner :  it  would  be  wrong,  however,  to  conclude  from 
the  above,  that  the  assistance  of  art  will  be  always  required  merely 
because  the  pelvic  extremity  of  the  child  presents  ;  on  the  con- 
trary, I  think  that  we  should  always,  in  such  cases,  abandon  the 
labour  to  the  resources  of  the  organism,  except  an  opposite  con- 
duct should  be  imperiously  demanded  by  some  peculiar  circum- 
stances. If  the  rupture  of  the  membranes  does  not  occur  until  after 
the  complete  dilatation  of  the  os  uteri,  if  the  position  is  regular 
and  the  pains  good,  the  foetus  will,  indeed,  pass  out  without  running 
much  more  risk  than  in  a  delivery  by  the  head  ;  but  if  the  mem- 
branes give  way  very  early,  if  the  least  traction  be  employed  under 
the  pretext  of  hastening  the  delivery,  it  is  certain  that  difliculties 
will  be  infinitely  multiphed,  and  the  life  of  the  child  seriously  com- 
promitted.  This  is  a  point  which  young  students,  as  well  as  prac- 
titioners, ought  never  to  lose  sight  of  This,  also,  is  one  of  the  mp- 
tives  that  have  induced  me,  both  in  my  lectures  and  in  this  work,  to 
deviate  from  the  ideas  generally  received  among  us  in  relation  to 
pelvic  presentations  of  the  foetus. 

769.  Previously  to  the  time  when  De  la  Motte,  Petit  and  Bau- 
delocque  had  demonstrated  that  the  somerset  motion  described  by 
their  predecessors  was  a  mere  chimera  ;  as  long  as  it  was  supposed 
that  the  foetus  naturally  remained  squatting  on  the  sacro-vertebral 
angle  until  the  end  of  the  seventh  month  of  pregnancy,  there  was 
no  diflicuUy  in  accounting  for  the  presentations  of  the  breech,  knees 
or  feel ;  to  explain  their  occurrence,  it  was  sufficient  to  say  that 
something  had  prevented  the  somerset  from  taking  place  ;  that  the 
child,  either  through  forgetful ness,  weakness,  or  something  else,  had 
allowed  the  opportune  moment  for  performing  this  pretty  feat  to 


PRESENTATION  OF  THE  PELVIS.  315 

elapse  ;  but  at  present,  when  we  cannot  resort  to  this  subterfuge, 
we  are  brought  to  confess  that  the  causes  of  presentations  of  the 
pelvis  are  but  little  known. 

770.  It  is  probable  that,  about  the  period  when  the  length  of  the 
occipito-coccygeal  diameter  of  the  foetus  begins  to  exceed  that  of 
the  transverse  or  horizontal  diameter  of  the  womb,  it  may  happen 
that  the  head  of  the  child,  being  carried  upwards  by  some  sudden 
movement,  by  the  decubitus  of  the  woman,  or  some  other  cause,  cannot 
resume  its  original  position.  It  has  been  observed  at  the  Maison 
d'Accouchemens  at  Paris,  and  I  have  had  occasion  myself  to  notice 
it,  that  presentations  of  the  pelvic  extremity  are  much  more  com- 
mon in  abortions  and  in  twin  pregnancies  than  in  simple  labours  oc- 
curring at  full  term  ;  and  this  remark  might  perhaps  be  used  to 
sustain  the  above  explanation  ;  but  how  can  we  refer  the  cause  of 
this  anomaly  to  the  fcetus,  or  to  mere  peculiarities  of  attitude  in  the 
mother,  in  those  tolerably  numerous  cases,  where  all  the  deliveries 
of  one  individual  terminate  in  this  way,  and  when  it  is  well  under- 
stood that  a  woman  having  once  been  delivered  of  a  breech  pre- 
sentation, warrants  us  in  fearing  that  it  will  happen  so  to  her  again  ? 
Would  it  not,  rather,  be  reasonable  to  seek  for  this  cause  in  the 
conformation  of  the  womb  or  pelvis  in  such  a  case  ? 

771.  The  positions  of  the  pelvic  extremity  may,  Hke  those  of 
the  head,  be  divided  into  regular  and  irregular  or  deviated  ones.  In 
the  former,  the  thighs  are  applied  against  the  abdomen,  the  legs  are 
bent  upon  the  thighs,  and  the  breech  and  feet  present  together  at  the 
superior  strait,  and  the  great  occipito-coccygeal  axis  is  parallel  to 
the  axis  of  the  pelvic  circle.  In  the  latter,  the  foetus  is  more  or 
less  inclined  to  the  right  or  left,  forwards  or  backwards  ;  the  pos- 
terior surface  of  the  coccyx,  or  one  of  the  tuberosities  of  the 
ischia,  or  the  forepart  of  the  legs  and  the  sexual  organs,  corres- 
pond to  the  centre  of  the  pelvis  ;  most  generally,  the  latter  are  re- 
duced to  the  former  as  soon  as  the  waters  are  gone  off ;  in  other 
instances  they  maintain  themselves  for  a  much  longer  time,  retard 
the  labour,  and,  in  certain  cases  entirely  prevent  it  from  terminat- 
ing spontaneously. 

772.  The  regular  positions  may  also  become  irregular,  especially 
after  the  rupture  of  the  membranes,  either  because  the  feet  con- 
tinue to  descend  pressed  against  the  breech ;  or  because  one  of 
the  legs  rises  up  on  the  anterior  surface  of  the  trunk,  while  the 
other  is  extended,  and  descends  first ;  or  because  one  of  them  be- 
comes situated  transversely,  so  that  the  knee  and  heel  press  on  two 
opposite  points  of  the  strait ;  or  because  one  knee  descends  together 
with  a  foot  or  a  buttock,  or  one  of  the  legs  is  turned  up  in  front,  and 


316  UNNATURAL  EUTOCIA. 

the  other  back  ;  or  lastly,  because  this  last  mentioned  condition  is 
met  with  concurrently  with  one  knee,  one  foot,  or  a  foot  and  buttock 
together,  &c. ;  but  in  general,  they  remain  frank  until  the  conclusion 
of  the  labour.  The  two  legs  and  thighs  then  extend,  and  the  feet 
escape  first.  At  other  times,  again,  the  legs  rise  upwards  and  the 
child  comes  away  doubled,  or  by  the  breech  properly  so  called. 
In  other  instances,  the  knees  alone  descend  together,  the  feet  con- 
tinuing to  be  applied  to  the  ischia,  which  constitutes  presentation 
of  the  knees  :  whence  it  results,  that  there  are  really  no  primitive 
presentations  of  the  feet  nor  of  the  knees,  and  that  until  the  rup- 
ture of  the  membranes,  there  are  no  other  positions  except  those 
of  the  breech. 

Thus  these  various  kinds  of  positions  ought  to  be  considered  only 
as  shades  of  a  single  and  even  fundamental  species,  the  presentation 
of  the  pelvic  extremity  of  the  foetus. 

773.  Instead  of  six,  Baudelocque  proposes  only  four  positions 
for  the  breech,  feet  and  knees ;  in  the  first  the  back  looks 
forward  and  to  the  left,  forwards  and  to  the  right  in  the  second, 
directly  forward  in  the  third,  and  directly  backwards  in  the 
fourth.  MM.  Capuron  and  Maygrier  have  rejected  the  two  latter, 
and  substituted  for  them  two  diagonal  positions,  which  renders  their 
classification  of  the  pelvic  positions  in  all  respects  similar  to  the  one 
they  thought  proper  to  establish  for  the  head.  Madame  Lachapelle 
has  acted  difl^erently  ;  she  retains  Baudelocque's  third  and  fourth  ; 
but  in  place  of  the  first  and  second,  she  admits  two  others,  in 
which  the  back  looks  directly  towards  the  right,  or  towards  the  left 
side  of  the  pelvis. 

One  thing  seems  to  me  to  be  proved  by  this  discrepancy :  it  is, 
that  we  might,  strictly  speaking,  establish,  as  M.  Flamant  has  done, 
eight  positions  of  the  breech.  But,  on  the  subject  of  the  pelvic 
extremity,  I  shall  repeat  what  i  said  in  relation  to  the  cephalic  ex- 
tremity :  disagreement  has  arisen  on  the  subject,  because,  instead 
of  seeking  every  possible  number  and  kind,  we  ought  to  endeavour 
to  ascertain  only  such  as  it  might  be  useful  to  know. 

774.  Admitting  that  it  were  not  perfectly  correct  to  say,  with 
Mauriceau,  Dionis,  De  la  Motte,  and  Levret,  that  the  loins  are,  in 
breech  cases,  most  generally  turned  backwards,  MM.  Capuron, 
Maygrier,  Duges,  &c.  would  not  be  less  in  the  wrong  to  assert  that 
they  as  well  as  the  sacro-anterior  positions  are  purely  hypothetical : 
Asdrubali,  who  has  noticed  them,  partakes  the  opinion  of  Mauri- 
ceau, and  of  Smellie  ;  and  the  tables  published  by  Madame  Lacha- 
pelle show  that  out  of  1390  cases  wherein  the  pelvic  extremity  pre- 
sented, there  were  thirteen  anterior,  and  twenty-six  posterior  ones. 


PRESENTATIONS  OF  THE  PELVIS.  317 

775.  Thus  the  direct  positions,  either  anterior  or  posterior,  are 

possible,  as  well  as  the  diagonal  ones,  and  the  breech  may  present 
in  as  many  ways  as  the  head.  Like  those  of  the  head,  too,  these 
positions  may  be  reduced  to  two  principal  ones  :  the  one,  sacro-an- 
terior,  and  the  other  sacro-posterior.  This  is  the  way  the  ancients 
understood  them,  and  if  Baudelocque  could  be  satisfied  with  one 
position  for  the  posterior  semi-circle  of  the  pelvis,  I  see  not  why 
the  three  positions  of  its  anterior  semi-circle  should  deserve  a  more 
special  description.  In  the  first,  second,  and  third  positions  of  that 
author,  whether  the  hips  engage  just  transversely  or  somewhat  ob- 
liquely, it  always  happens  that  one  of  them  looks  to  the  left  and  the 
other  to  the  right,  exactly  as  in  the  three  posterior  varieties.  In 
the  first  case  the  occiput  always  ends  by  placing  itself  behind  the 
pubis ;  in  the  second  it  proceeds  to  lodge  on  the  fore  part  of  the 
sacrum,  as  is  observed  to  happen  in  the  corresponding  positions  of 
the  vertex.  The  anterior  position  differs  essentially  from  the  pos- 
terior one  ;  but  the  two  last  being  admitted  as  possible,  it  is  quite 
useless,  as  to  practice,  to  establish  others,  except  as  shades  of  them. 
Notwithstanding,  out  of  respect  for  received  opinions,  I  shall  not 
fail  to  point  out  the  particular  mechanism  of  each  one  of  these 
shades,  and  instead  of  uniting  all  the  positions  of  the  pelvic  ex- 
tremity in  one  single  genus,  I  shall  for  the  same  reason  continue  to 
examine  separately  those  of  the  feet,  the  knees  and  breech. 

§.  I.  Presentation  of  the  feet. 

538  out  of  37,895,  Madame  Lachapelle  ;  23  in  1800,  Merriman ;  18  in  1897, 
Bland ;  68  in  6555,  Boer. 

776.  What  I  have  stated  in  relation  to  the  dangers  of  delivery  by 
the  pelvic  extremity,  applies  strictly  to  presentations  of  the  feet.  In 
that  case  the  child  resembles  a  cone  or  a  very  sharp  wedge,  descend- 
ing from  its  point  towards  its  base  ;  the  bag  of  waters  being  generally 
less  regular  in  shape,  more  elongated  than  in  other  positions,  and 
almost  always  rupturing  before  the  dilatation  of  the  neck  has  had  time 
to  be  completed,  it  follows  that  the  pressure  upon  the  fcEtus  constantly 
increases  from  the  root  of  the  lower  limbs  up  to  the  superior  part  of 
the  chest,  and  that  the  viscera  are  violently  repelled  from  below  up- 
wards ;  in  one  word,  the  parts  of  the  woman  are  dilated,  and  a  passage 
for  the  head  opened  by  the  hips,  the  belly,  and  the  thorax.  If  the  ab- 
dominal and  thoracic  cavities  were  formed  of  bones  as  solid,  and  if 
their  horizontal  diameters  were  of  length  equal  to  those  of  the  head, 
they  would  bear  the  pressure  of  the  os  uteri  with  quite  as  little  in- 
convenience, and  the  child  would  not  run  much  more  risk  in  one 
way  than  in  the  other ;  but  this  is  not  the  case,  and  I  cannot  too 
strongly  insist  upon  the  disadvantages  of  such  presentations. 


318  UNNATURAL  EUTOCIA. 

1.  Calcaneo- Anterior  Position. 
347  in  37,895  cases,  Madame  Lachapelle. 

A.  First  Variety. 

Loins  in  front  and  towards  the  left. 

1st  position  of  Baudelocque,  Gardien,  Maygrier,  Capuron,  Madame  Boivin  and 
M.  Desormeaux. 

777.  In  the  first  position  of  the  feet,  the  anterior  surface  of  the 
foetus  looks  backwards  and  to  the  right  of  the  womb  ;  the  right  hip 
is  turned  towards  the  left  sacro-iliac  symphysis,  and  the  left  hip  to- 
wards the  right  acetabulum  ;  whence  it  follows,  that  if  the  presence 
of  the  rectum  were  the  principal  cause  of  the  great  proportional 
frequency  of  the  first  vertex  position,  the  first  position  of  the  feet 
ought  to  be  more  rarely  met  with  than  the  second  ;  however,  the 
contrary  is  observed  to  happen  ;  for,  by  the  statement  of  Madame 
Boivin,  in  a  total  of  234  labours  by  the  feet,  the  left  calcaneo-aceta- 
bular  position  alone  occurred  135  times. 

778.  The  heels,  which  previously  to  the  rupture  of  the  mem- 
branes are  more  or  less  near  to  the  tuberosities  of  the  ischia,  do  not 
actually  engage  within  the  os  uteri,  until  the  moment  when  the 
waters  run  off,  and  sometimes  even  much  later  than  that.  If  the 
amnios  does  not  give  way  until  after  the  orifice  is  properly  dilated, 
the  legs  and  thighs  follow  the  feet  immediately,  and  the  hips,  which 
traverse  the  superior  strait  in  a  diagonal  position,  soon  reach  the 
vulva.  In  the  contrary  case,  all  these  parts  descend  slowly,  and  by 
degrees,  with  each  returning  pain.  The  fcetal  pelvis,  before  it  en- 
gages into  the  inferior  strait,  generally  performs  a  rotation  upon  the 
right  anterior  and  left  posterior  inclined  planes  of  the  excavation  ; 
the  left  hip  occupies  the  arch  of  the  pubis,  while  the  right  hip  goes 
to  fill  up  the  hollow  of  the  sacrum.  The  whole  child  bends  upon  its 
anterior  or  left  side  ;  the  belly  next  passes  through  the  os  uteri ;  the 
elbows,  pressed  against  the  ribs,  or  somewhat  in  front  upon  the 
breast,  yield  to  the  contractions  of  the  womb,  and  descend  along 
with  the  thorax  into  the  excavation.  The  shoulders  follow  the 
chest  through  the  abdominal  opening  of  the  pelvis,  where  they  re- 
main in  the  same  direction  they  aflected  at  the  commencement  of 
the  labour,  that  is  to  say,  diagonally,  the  right  before  the  left  sacro- 
iliac symphysis,  and  the  left  behind  the  right  acetabulum.  When 
below  the  strait,  they  are  subjected  to  the  same  pivot  motion  as  the 
hipji,  and  like  them,  are  soon  placed  in  the  antero-posterior  direc- 
tion. The  head,  strongly  flexed,  follows  the  upper  part  of  the  breast ; 
the  ovoid  which  it  represents  engages  with  its  apex  foremost ;  its 


PRESENTATIONS  OF  THE  PELVIS.  *   319 

occipito-mental  diameter  is  parallel  with  the  axis  pf  the  strait,  the 
"plane  of  which  soon  becomes  parallel  to  the  occipito-bregmatic  cir- 
cumference ;  the  bi-parietal  and  occipito-bregmatic  diameters  mea- 
sure the  oblique  diameters  ;  in  fine,  the  relations  of  the  head  to  the 
upper  pelvic  circle  are  absolutely  the  same  as  in  the  first  position  of 
the  vertex  :  there  is  only  this  difference,  that  the  small,  instead  of 
the  large  extremity  of  the  cone  represented  by  the  head,  videl.  the 
chin,  the  face  and  base  of  the  skull — instead  of  the  superior  oval  and 
occiput — advance  foremost. 

779.'  The  root  of  the  umbilical  cord,  the  abdomen,  and  the  lower 
part  of  the  thorax  are  now  emerged ;  the  left  elbow  appears  at  the 
top  of  the  pubic  arch ;  the  right  elbow,  arm  and  shoulder  slide  gra- 
dually along  the  sacrum  and  perineum,  and  successively  appear  in 
front  of  the  posterior  commissure  of  the  vulva,  which  strongly  raises 
the  trunk  of  the  foetus  up  towards  the  mons  veneris ;  so  that  the 
shoulder  that  is  in  front  does  not  commonly  disengage  itself  until 
after  the  other,  although  the  corresponding  elbow  had  appeared  at 
the  vulva  first.  Immediately  after  this,  if  not  supported,  the  child 
falls  backwards  again  by  its  own  weight,  and  rests  on  the  anterior 
edge  of  the  perineum  ;  a  kind  of  movement  of  restitution  which 
again  carries  the  left  shoulder  to  the  right,  and  the  right  one  to  the 
left  side,  soon  takes  place,  and  the  bis-acromial  again  crosses  the 
occipito-bregmatic  diameter  at  right  angles. 

780.  When  fairly  in  the  excavation,  the  head  revolves  on  its 
occipito-mental  diameter,  so  as  to  carry  the  face  directly  backwards, 
and  the  nape  of  the  neck  and  occiput  directly  in  front ;  the  two  ex- 
tremes of  the  occipito-bregmatic  diameter  slide  from  right  to  left, 
and  from  before  backwards,  on  the  right  posterior  inclined  plane, 
and  from  left  to  right  and  from  behind  forwards,  on  the  left  anterior 
inclined  plane,  as  in  the  first  vertex  position,  so  as  to  become  parallel 
to  the  coccy-pubal  diameter.  The  womb  can  now  no  longer  act 
immediately  upon  the  head,  which  is  entirely  or  partly  in  the  vagina ; 
but  the  disposition  to  straining,  produced  by  the  pressure  now  ex- 
perienced by  the  rectum  and  bladder,  soon  compels  the  woman  to 
gather  up  all  her  powers  and  redouble  her  courage,  and  the  contrac- 
tions of  the  abdominal  muscles  soon  come  to  the  assistance  of  the 
powerless  womb,  for  whose  forces  they  are  now  the  substitutes. 
From  this  moment  the  occiput  receives  the  whole  weight  of  the  ex- 
pulsive power  :  in  order  that  it  may  become  parallel  to  the  axis  of 
the  perineal  strait,  the  occipito-mental  diameter  gradually  executes 
a  see-saw  motion,  which  brings  the  anterior  fontanel  near  to  the 
anterior  surface  of  the  hollow  of  the  sacrum,  and  causes  the  chin  to 
thrust  the  breast  towards  the  symphysis  of  the  pubis.     Finally,  the 


320  UNNATURAL  EUTOCIA. 

nape  of  the  neck,  bearing  upon  the  summit  of  the  arch,  as  upon  a 
fixed  axis,  permits  the  head  to  describe  an  arc  of  a  circle,  the  radii 
of  which  seem  to  have  the  lower  edge  of  the  articulation  for  their 
centre,  and  to  be  composed  of  the  occipito-mental,  occipito-frontal, 
occipito-bregmatic,  and  vertical  diameters  ;  so  that  we  see  the  chin, 
the  forehead,  and  the  anterior  fontanel  appear  in  regular  succession 
at  the  vulva,  after  which  the  occiput  escapes  from  above  downwards, 
and  emerges  thus  from  the  pelvis  to  put  an  end  to  the  labour. 

B.  Second  Variety. 
Loins  forward  and  to  the  right. 
2d  position  of  Baudelocque,  Gardien,  Capuron,  Maygrier,  Desormeaux  and 
Duges  ;  86  times  in  234  feet  presentations,  Madame  Boivin  ;  175  in  37,895  la- 
bours, Madame  Lacbapelle. 

781.  In  the  right  calcaneo-acetabular  position,  the  soles  of  the 
feet,  the  fore  parts  of  the  legs,  and  the  whole  anterior  surface  of  the 
foetus  look  towards  the  left  and  back  part  of  the  mother ;  the  right 
side  is  towards  the  front  and  left  of  the  mother. 

The  feet  and  legs,  as  in  the  preceding  position,  are  not  mechani- 
cally stretched  out,  are  not  really  pushed  into  the  orifice,  until  after 
the  perforation  of  the  membranes.  The  hips,  arms,  and  shoulders 
pass  through  the  straits  and  present  themselves  at  the  vulva  in  the 
same  way  ;  that  is  to  say,  diagonally  at  the  superior  strait,  and 
antero-posteriorly  at  the  inferior  strait ;  but  the  act  of  rotation  takes 
place  from  left  to  right  instead  of  from  right  to  left,  as  before :  both 
the  right  hip  and  right  shoulder,  and  not  the  corresponding  parts  of 
the  left  side,  proceed  to  lodge  in  the  arch  of  the  pubis  ;  the  abdomi- 
nal surface  turns  towards  the  left,  and  thus  takes  the  situation  of  the 
posterior  surface,  which  now  looks  towards  the  right  iliac  fossa ; 
the  occipito-mental  and  bi-parietal  diameters,  and  the  occipito-breg- 
matic diameter  and  circumference,  preserve  the  same  relations  with 
the  axis,  the  oblique  diameters  and  plane  of  the  superior  strait,  and 
with  the  coccy-pubal  and  bi-sciatic  diameters  of  the  inferior  strait ; 
but  the  face  and  forehead  are  obliged  to  descend  along  the  front  of 
the  sacro-iliac  symphysis,  and  the  pivot  motion  occurs  along  the 
right  anterior  and  left  posterior  inclined  planes  ;  in  one  word,  the 
second  position  differs  no  more  from  the  first  than  the  left  hand  does 
from  the  right ;  and  the  mechanism  of  the  one  is  so  similar  to  that 
of  the  other,  that  it  would  be  really  fastidious  to  enter  into  any  longer 
details  concerning  it. 


PRESENTATIONS  OF  THE  PELVIS.  321 


C.  Third  Variety. 
Loins  directly  in  front. 
Sd  position,  Baudelocqua,  MM.  Gardien,  Maygrier,  Capuron,  Desormeaux, 
jcc. ;  7  in  264,  Madame  Boivin ;  6  in  235,  Madame  Lachapelle. 

782.  It  is  true  we  find  undoubted  instances  of  the  third  position 
in  Mauriceau,  Smellie  and  Levret,  &c.;  but  as  these  authors,  as  well 
as  de  La  Motte,  Deleurye,  and  Asdrubali,  did  not  distinguish  them 
from  the  two  preceding  ones,  we  cannot  ascertain  in  what  propor- 
tion they  met  with  them.  Be  this  as  it  may,  we  do  not  perceive 
that  the  form  of  the  strait  can  in  any  way  prevent  such  a  presenta- 
tion from  taking  place ;  the  pelvis  is  wide  enough  in  front  to  admit 
of  the  two  hips  engaging  in  it  transversely ;  the  sacro-vertebral  angle 
might  very  well  lodge  betwixt  the  thighs  or  legs  of  the  child,  whether 
flexed  or  extended ;  the  belly  and  breast  are  too  easily  depressed  to 
occasion  the  least  difficulty  in  this  respect ;  and  the  shoulders  them- 
selves would  pass  transversely  through  the  strait  as  easily  as  the  hips. 
As  to  the  head,  although  in  penetrating  to  the  excavation  it  would 
not  experience  more,  or  might  have  even  less  difficulty,  than  if  the 
vertex  were  presented  in  the  third  position,  it  notwithstanding  rarely 
fails  to  deviate  to  the  right  or  left  side  of  the  promontory.  It  is  easy 
to  see  that  in  this  respect  there  has  been  more  dispute  about  words 
than  things.  In  fact,  if  those  accoucheurs  who  reject  the  third  po- 
sition of  the  feet,  admit  under  that  title  only  those  cases  where  the 
middle  line  of  the  child's  back  glides  along  behind  the  symphysis  pubis 
to  the  very  close  of  labour,  they  are  no  doubt  partly  right,  and  such 
a  labour  must  be  extremely  rare  ;  but  if,  on  the  contrary,  in  order 
to  constitute  such  a  case,  it  suffices  for  the  child  to  descend  in  this 
way  until  the  arrival  of  the  head  only,  we  are  not  permitted  to  be 
ignorant,  not  merely  of  its  possibility,  but  also  of  its  very  great 
frequency. 

During  the  progress  of  the  labour,  then,  this  third  position  almost 
always  converts  itself,  a  little  sooner  or  later,  into  the  first  or  second  ; 
sometimes  it  lasts  only  until  the  arrival  of  the  hips  at  the  superior 
strait ;  sometimes  it  maintains  itself  until  the  shoulders  engage ; 
sometimes  it  is  not  converted  into  a  diagonal  position  until  the  breast 
has  descended  quite  into  the  excavation  ;  finally,  it  may  happen  that 
it  does  not  become  converted  at  all,  and  then  one  of  two  things  is 
observed  to  take  place  :  either  the  hips,  the  shoulders,  and  the  head 
do  not  turn  upon  their  axes  at  the  abdominal  strait,  in  the  excava- 
tion, nor  at  the  inferior  strait,  and  the  child's  back  cojitinues  to  look 
to  the  front  of  the  mother  both  out  of  the  pelvis  and  inside  of  it,  and 
2Q 


322  UNNATURAL  EUTOCIA. 

there  is  no  pivot  movement  within  the  pelvis,  nor  restitution  nor 
rotation  outside  of  it ;  or,  on  the  other  hand,  the  hips  and  shoulders, 
which  were  engaged  transversely  at  the  upper  strait,  place  them- 
selves in  an  antero-posterior  direction  to  pass  through  the  vulva — in 
which  case  the  head  is  the  only  part  that  does  not  turn  on  its  axis. 

2.  Calcaneo-Posterior  Position. 
4lh  position  of  Baudelocque,  MM.  Gardien,  Desormeaux,  &c.;  10  in  538,  Ma- 
dame Lachapelle;  6  in  234,  Madame  Boivin. 

783.  Under  the  title  of  fourth  position,  Baudelocque  comprised 
all  the  cases  where  the  dorsal  surface  of  the  fcetus  looks  towards 
any  point  of  the  posterior  half  of  the  superior  strait,  and  not  merely 
those  in  which  it  is  turned  directly  backwards,  as  we  might  be 
tempted  to  believe  from  reading  a  great  number  of  modern  works. 
In  this  respect  he  has  only  imitated  Mauriceau,  Dionis,  De  La 
Motte,  Portal,  Smellie,  Asdrubali,  &.c. 

In  the  usual  folded  state  of  the  foetus,  the  soles  of  the  feet,  the 
fore  parts  of  the  legs,  and  the  forehead  and  abdominal  surface  of 
the  child  are  directed  forwards.  The  lower  limbs  being  more  or 
less  rapidly  extended  and  elongated  by  the  uterine  contractions, 
they  pass  through  the  vagina,  and  reach  the  vulva  ;  the  hips  soon 
follow,  and  sometimes  pass  the  superior  strait  in  the  direction  of  the 
bis-iliac  diameter,  more  frequently  in  that  of  one  of  the  oblique  ones, 
or  at  least,  after  being  slightly  inclined,  one  forwards  and  the  other 
backwards,  provided  they  were  previously  quite  transverse.  When 
in  the  excavation,  they  are  observed  to  engage  in  the  perineal  strait, 
sometimes  parallel  with  the  bi-sciatic  line,  at  others  by  following 
the  oblique  diameter,  and  most  frequently,  after  one  of  them  has 
been  placed  behind  the  symphysis  pubis,  and  the  other  in  front  of 
the  sacrum. 

784.  The  arms  and  shoulders  present  themselves  in  their  turn, 
and  act  like  the  hips,  with  the  exception  only,  that  they  more  rarely 
fail  to  execute  the  pivot  motion  before  they  pass  through  the  vulva, 
even  though  they  had  previously  affected  a  transverse  position  ; 
being  repelled  by  the  anterior  edge  of  the  perineum,  these  different 
parts,  as  they  emerge,  are  raised  upwards  towards  the  mons  veneris  ; 
to  accommodate  itself  to  the  curve  of  the  pelvis  and  genital  parts, 
the  fcBtus  bends  in  the  shape  of  a  very  long  arc  of  a  circle,  convex 
behind  and  concave  before,  as  it  does  in  an  anterior  position.  The 
elbow  that  is  below  the  pubis  shows  itself  first  at  the  upper  part  of 
the  vulva ;  but  the  opposite  arm  and  shoulder,  more  particularly 
urged  by  the  efforts  of  the  womb,  proceed  from  behind  forwards 


PRESENTATIONS  OF  THE  PELVIS.  323I 

along  the  posterior  median  line,  and  actually  are  the  first  to  escape 
from  the  pelvis  ;  the  edge  of  the  perineum  immediately  afterwards' 
retires  upon  the  neck,  as  if  to  permit  the  trunk  to  fall  back  towards 
the  anus,  and  the  other  shoulder  to  disengage  from  beneath  the 
pubic  symphysis  ;  the  back  then  turns  back  again,  as  by  a  sort  of 
movement  of  restitution,  which  replaces  the  shoulders,  the  one  to 
the  left  and  the  other  to  the  right,  or  diagonally.  The  head  cannot 
become  engaged  without  being  strongly  flexed  ;  on  the  one  hand 
the  occiput  almost  invariably  deviates  towards  one  of  the  sacro-iliac 
symphyses  ;  on  the  other,  the  occipito-frontal  diameter,  or  even  the 
entire  head,  represents  a  lever  of  the  first  kind,  whose  anterior  ex- 
tremity more  particularly  supports  the  action  of  the  expulsive  pow- 
ers ;  the  chin,  although  more  or  less  prevented  by  the  breast,  ends 
however  by  being  depressed,  and  the  occipito-mental  diameter  by 
finding  itself  almost  parallel  with  the  axis  of  the  strait ;  the  forehead 
and  anterior  fontanel  come,  one  after  the  other,  to  hide  behind  the 
symphysis  of  the  pubis,  and  thenceforth  the  occipito-bregmatic  cir- 
cumference is  in  correspondence  with  the  plane  of  the  pelvic  mar- 
gin, as  in  all  the  anterior  positions. 

786.  When  in  the  excavation,  the  head  rolls  on  the  inchned  planes, 
replaces  itself  in  an  antero-posterior  direction  by  means  of  the  pivot 
motion,  and  afterwards  glides  with  much  more  difficulty  than  when 
the  occiput  is  forwards  ;  the  breast,  which  is  situated  in  front,  opposes 
the  lowering  of  the  chin  ;  the  occipito-bregmatic  diameter,  which  is 
three  and  a  half  inches  long,  not  being  able  to  place  itself  in  cor- 
respondence with  the  antero-posterior  diameters  of  the  excavation 
and  apex  of  the  pelvis,  has  its  place  occupied  by  the  occipito-frontal 
diameter,  which  has  an  extent  equal  to  at  least  four  inches.  The 
face,  and  particularly  the  forehead,  are  too  broad  and  ill-disposed 
to  fit  the  form  of  the  pubic  arch  so  exactly  as  the  nape  of  the  neck 
and  occiput  do ;  finally,  the  shoulders  hardly  emerge  before  the  chin 
presents  itself  at  the  vulva. 

Nevertheless,  immediately  after  the  expulsion  of  the  thorax  and 
upper  extremities,  the  upper  and  hinder  part  of  the  neck  rolls  from 
before  backwards  upon  the  anterior  edge  of  the  perineum,  as  upon 
an  axis,  and  the  nose,  the  forehead,  the  anterior  fontanel  and  remain- 
der of  the  head  successively  disengage,  by  forcing  the  breast  back- 
wards. 

786.  Remarks.  The  mechanism  of  this  position,  as  now  seen, 
is  very  unfavourable,  and  much  more  difficult  than  that  of  the 
calcaneo-anterior  positions ;  if  the  chin  or  forehead  lodge  upon  the 
upper  edge  of  the  pubis,  the  act  of  flexion  of  the  head  is  prevented 
or  destroyed,  and  the  occipito-raental  diameter,  or  the  occipito- 


324  UNNATURAL  EUTOCIA. 

frontal  diameter  and  circumference,  occupy  the  situation  of  the 
occipito-bregmatic  diameter  and  circumference;  then  the  labour 
cannot  be  terminated  without  assistance. 

It  would,  notwithstanding,  be  wrong  to  conclude  that  art  must  of 
necessity  aid  the  economy  in  all  the  posterior  positions  of  the  feet : 
attempts  to  change  them  would  favour  the  reversion  of  the  head, 
and  most  frequently  produce  just  the  state  of  things  which  it  is  de- 
sired most  carefully  to  avoid.  Besides,  nature,  when  left  to  herself, 
generally  succeeds  better  than  any  foreign  power  in  flexing  the  head 
and  placing  it  diagonally  at  the  superior  strait.  In  a  very  great 
majority  of  cases  this  position  spontaneously  converts  itself  into  an 
anterior  position,  either  suddenly,  after  the  head  has  got  into  the 
excavation,  or,  on  the  other  hand,  gradually,  in  proportion  as  the 
hips,  the  shoulders,  and  the  head  itself  present. 

787.  In  a  case  of  this  kind  I  have  seen  the  hips  emerge  trans- 
versely from  the  vulva,  turn  in  the  direction  of  the  oblique  diameter 
that  extends  from  behind  and  right  to  the  left,  then  place  itself  in  the 
antero-posterior  direction,  as  the  shoulders  became  engaged,  then 
continue  their  rotation  movement  after  the  escape  of  the  latter,  and 
at  last  turn  quite  across,  with  the  back  in  front,  yet  the  head  escape 
as  in  a  direct  anterior  position.  Now,  this  is  what  almost  always 
happens  if  the  accoucheur  is  skilful  enough  to  do  nothing,  to  content 
himself  with  sustaining  the  fcetus,  as  it  passes  the  vulva,  without 
employing  the  least  traction. 

788.  If  the  loins  are  sometimes  turned  directly  to  the  left  or  right, 
which  cannot  be  doubted,  inasmuch  as  Madame  Lachapelle  informs 
us  that  she  has  seen  it  so,  we  may  be  at  least  allowed  to  suppose 
that  in  this  direction  persons  have  been  often  deceived  by  the  ob- 
lique position  that  approaches  most  nearly  to  it.  But  for  this,  the 
celebrated  midwife  would  not  have  said  that  out  of  1038  labours  by 
the  feet,  there  were  found  to  be  347  left  iliac  positions,  and  175 
right  iliac  positions ;  moreover,  by  the  admission  of  Madame  La- 
chapelle herself,  the  really  lateral  positions  almost  always  convert 
themselves  into  anterior  or  posterior,  diagonal  or  direct  positions. 

789.  In  all  the  feet  positions,  the  hips  and  shoulders  ordinarily 
execute  a  rotation  movement,  previously  to  engaging  in  the  inferior 
strait ;  according  to  Baudelocque,  this  movement  may,  however, 
possibly  not  take  place,  and  the  parts  may  therefore  continue  parallel 
to  the  bi-sciatic  diameter  ;  according  to  most  of  the  modern  accou- 
cheurs, on  the  contrary,  the  hips  and  shoulders  almost  never  pass 
the  vulva  otherwise  than  parallel  with  the  coccy-pubal  diameter. 
To  reconcile  these  two  extremes,  there  remained  one  intermediate 
opinion,  and  Madame  Lachapelle  embraced  it,  maintaining  that  the 


PRESENTATIONS  OF  THE  PELVIS.  3^  ^ 

pelvis  and  upper  part  of  the  thorax  pass  through  the  inferior  strait, 
in  an  oblique  or  diagonal  direction,  and  not  in  a  directly  transverse 
nor  antero-posterior  direction,  strictly  so  called.  For  my  own  part, 
if  I  can  believe  my  own  eyes,  both  parties  are  right,  an  error  is 
found  only  in  the  exclusion  by  which  each  party  endeavours  to 
put  down  the  other. 

790.  All  the  accoucheurs,  both  ancient  and  modern,  have  main- 
tained, that  in  delivery  by  the  feet,  the  arms  rise  along  the  sides  of 
the  neck  and  head.  Wiedemann  was  one  of  the  first  to  oppose  this 
doctrine,  and  he  pretends  that  they  always  remain  applied  against 
the  breast,  if  no  tractions  of  any  kind  are  exercised  upon  the  foetus. 
M.  Desormeaux  and  Madame  Lachapelle  adopted  this  opinion  also. 
In  the  deliveries  by  the  feet  that  have  fallen  under  my  notice,  the 
forearms  and  elbows  did  not  abandon  the  breast,  and  always  escaped 
before  the  shoulders,  when  the  woman  was  left  to  her  own  powers, 
and  nothing  more  was  done  than  to  support,  without  pulling  at  the 
trunk  until  the  expulsion  of  the  head. 

79 1 .  Though  so  many  authors  have  professed  the  opposite  opinion, 
which  still  prevails  very  generally,  it  depends  solely  on  the  circum- 
stance, that  the  persons  who  assist  lying-in  women,  rarely  consent 
to  remain  inactive  in  a  footling  delivery ;  they  lay  hold  on  the  mem- 
bers that  spontaneously  present,  and  the  very  natural,  and  in  itself 
considered,  laudable,  desire  to  put  an  end  to  the  sufferings  of  the 
mother,  causes  them  to  pull  with  more  or  less  force  upon  the  child, 
and  a  phenomenon  which  is  produced  merely  by  art,  is  then  very 
readily  mistook  for  a  natural  one.  Where  the  womb,  assisted  by 
the  muscular  contractions  of  the  abdomen,  is  alone  charged  with 
the  duty  of  expelling  the  ovum,  all  the  parts  of  the  child  are  pushed 
down  simultaneously,  and  so  folded  and  pressed  together,  that  it  is 
very  difficult  for  one  of  them  to  rise  upwards  while  the  others  are 
descending ;  as  the  uterus  does  not  contract  from  its  fundus  towards 
its  cervix  only,  but  also  circularly,  from  above  downwards,  by  a  sort 
of  vermicular  or  peristaltic  movement,  the  elbows  or  arms  run  no 
risk  of  lodging  against  the  upper  edge  of  the  pelvis. 

792.  If,  on  the  contrary,  the  foetus  is  extracted  and  not  simply 
expelled,  as  the  tractions  come  to  act  ultimately  upon  the  breast 
and  head,  it  follows,  that  these  parts  only  are  dragged  downwards, 
while  the  arms,  retained  in  their  position  by  the  womb,  remain 
where  they  were,  and  can  only  descend  in  a  direction  extending 
from  the  shoulders  towards  their  free  extremities. 

Nevertheless,  I  do  not  believe  it  right  to  deny,  as  Madame  La- 
chapelle does,  the  possibility  of  the  phenomenon  admitted  by  the  older 
accoucheurs  to  take  place  in  every  spontaneous  delivery.     We  may 


336  UNNATURAL  EUTOCIA. 

conceive  that  the  arms,  when  once  they  have  reached  the  excavation 
along  with  the  shoulders,  being  no  longer  directly  urged  by  the 
uterine  efforts,  may  rise  upwards  by  sliding  along  the  sides  and 
fore  part  of  the  breast,  or  rather,  that  the  head,  supporting  from  this 
moment,  the  whole  action  of  the  expulsive  powers,  may  cause  the 
face  and  breast  to  descend  into  the  inferior  strait,  without  necessa- 
rily carrying  the  elbows  along  with  them.  It  must  be  so,  further, 
since  M.  Gardien  affirms  that  in  many  labours  terminated  by  the 
feet  without  any  assistance,  he  has  seen  the  arms  rise  along  the  sides 
of  the  neck  and  head,  and  since  M.  Deneux  told  me  he  had  observed 
the  same  thing. 

Presentation  of  the  knees. 
4  in  20,517,  Madame  Boivin  ;  9  in  22,243,  Madame  Lachapelle. 

793.  The  position  of  the  knees  being  in  all  respects  like  that  of 
the  feet,  it  is  useless  to  give  the  mechanism  of  it  apart ;  in  fact, 
whether  the  legs  have  descended,  or  remain  bent  upon  the  thighs, 
the  lower  extremities  traverse  the  os  uteri  and  straits  of  the  pelvis 
with  equal  facility.  Perhaps  they  descend  with  rather  less  facility 
in  the  second  than  in  the  first  case  mentioned,  provided  the  mem- 
branes give  way  wlien  the  neck  is  still  incompletely  dilated ;  but  the  - 
knees  scarcely  reach  the  vulva  before  the  legs  become  extended,  and 
thenceforth  every  thing  proceeds  as  if  it  had  been  a  footling  case. 

The  knees  present  first,  because  they  have  been  reversed,  either 
mechanically  or  by  muscular  action,  in  the  cul  de  sac  formed  by  the 
apex  of  the  ovum,  at  the  moment  when  the  membranes  are  ruptured, 
or  because  the  rush  of  fluid  forces  them  along  with  it,  rather  than 
the  feet,  which  may  be  farther  from  the  orifice ;  or  because  the 
breech,  which,  presented  first,  mounts  upwards  again  along  with  the 
feet,  under  the  influence  of  the  contractions  of  the  womb,  so  that 
the  knees  only  can  be  depressed  into  the  opening  of  the  neck  ;  or 
yet  again,  because,  aflier  the  discharge  of  the  waters,  the  legs  are 
situated  crosswise  above  the  uterine  orifice,  or  have  been  arrested 
against  two  opposite  points  of  the  strait.  Moreover,  we  may  con- 
ceive that  they  may  both  descend  at  once,  or  only  one  of  them  atong 
with  one  foot,  without  that  circumstance  changing  the  progress  of 
the  labour  ;  and  it  was  entirely  wrong  to  attribute  more  danger  to 
delivery  by  the  knees,  than  to  those  that  take  place  by  the  feet. 

Presentation  of  the  breech. 
S87  in  87,896,  Madame  Lachapelle  ;  375  in  20,617,  Madame  Boivin ;  42  in 
1800,  Merriuian  ;  86  in  1897,  Bland;  126  in  6665,  Boer. 


-A 


PRESENTATIONS  OF  THE  PELVIS.  327 

794.  Presentation  of  the  breech  has  always  beqn  regarded  as 
more  dangerous,  difficult,  and  unnatural  than  that  by  the  feet  or 
knees.  It  was  thought  that  the  size  of  the  buttocks  would  not  admit 
of  the  expulsion  of  the  child  without  the  neck  of  the  womb  as  well 
as  the  perineum  being  violently  contused  or  extensively  lacerated  ; 
but  even  had  experience  not  pronounced  upon  the  value  of  these 
exaggerated  fears,  a  moment's  reflection  would  have  shown  how 
unfounded  they  were.  It  is  merely  necessary  to  recollect  the  di- 
mensions of  the  foetal  pelvis,  to  be  instantly  convinced  that,  even  to- 
gether with  the  thighs,  the  size  of  the  breech  could  never  form  an 
insurmountable  obstacle  to  delivery,  unless  there  were  some  faulty 
conformation  of  the  straits.  When  the  child  comes  doubled,  the 
pelvic  extremity  is  too  supple,  too  flexible,  and  accommodates  itself 
too  easily  to  the  form  of  the  openings  it  has  to  traverse,  for  it  to  ex- 
pose the  neck  of  the  uterus  and  the  perineum,  any  more  than  the 
head  does,  to  the  lacerations  of  which  we  have  spoken. 

795.  In  presentations  of  the  feet  or  knees,  the  bag  of  waters  is  in 
general  more  elongated,  tears  more  readily,  and  the  os  uteri  has  less 
need  of  being  so  largely  dilated.  With  the  breech,  on  the  contrary, 
the  amniotic  sac  is  as  large  as  in  a  head  presentation,  and  does  not 
open  until  it  has  produced  a  considerable  dilatation  ;  the  buttocks 
and  hips,  which  have  to  open  a  passage,  react  without  inconvenience 
against  the  resistance  of  the  neck  ;  the  belly  and  breast  pass  the 
straits  and  vulva  without  the  risk  of  a  very  violent  pressure  ;  for,  ex- 
cepting the  head,  the  hips  exceed,  as  to  dimensions  and  firmness,  any 
other  part  of  the  child. 

796.  In  breech  cases  it  is  true  that  the  labour,  in  general,  goes  on 
very  slowly  until  they  have  passed  through  the  cervix,  and  sometimes, 
even  until  they  have  traversed  the  vulva  ;  while  in  feet  or  knee  pre- 
sentations, it  seems,  at  first,  that  the  process  of  child-birth  is  going 
to  be  extremely  prompt.  But  these  differences  are  all  in  favour  of 
breech  positions ;  for  in  the  second  case,  the  phenomena  then  suc- 
ceed each  other,  producing  so  much  the  less  effect  as  the  body  is 
nearer  being  completely  expelled  ;  while  in  the  first  case,  where  the 
hips  have  once  descended  into  the  vagina,  the  rest  of  the  bo<^ 
emerges  with  much  less  difficulty.  I  dwell  upon  this  idea  because 
it  is  well  calculated  to  show  how  imprudent  it  may  be,  in  a  presen- 
tation of  the  pelvic  extremity,  to  bring  down  the  feet  artificially,  with 
the  sole  view  of  hindering  the  breech  from  engaging  first,  before  the 
dilatation  is  completely  eflfected. 

797.  Baudelocque  admits  four  positiops  for  the  breech,  as  he  does 
for  the  feet,  and  divides  them  in  the  same  manner ;  M.  Flaraant 


328  UNNATURAL  EUTOCIA. 

reckons  eight  of  them,  and  MM.  Maygrier  and  Capurbn,  four,  as 
for  the  head,  &c. 

798.  Without  speaking  of  the  cases  where  the  foetus  engages 
squatting,  having  the  heels  glued,  as  it  were,  against  the  ischia,  cases 
in  which  art  is  almost  always  required  for  the  assistance  of  nature, 
I  must  say  that  in  women  endowed  with  but  little  moral  and  mus- 
cular energy,  the  softness  and  flexibility  of  the  breech  will  absorb 
the  greater  part  of  the  motion  communicated  to  the  spine  of  the 
child  by  the  womb,  which  often  ends  by  falling  into  a  state  of 
inertia,  and  that  the  labour  cannot  then  be  always  abandoned  to 
itself  without  danger;  besides,  in  the  three  anterior  positions,  the 
external  organs  of  generation  of  the  male  sex  are  exposed  to  fric- 
tions more  or  less  violent  against  the  promontory ;  and  it  is  also  by 
no  means  rare  to  find  black  and  contused  echymoses  in  new  born 
children  that  come  by  the  breech. 

Whether  the  buttocks  have  passed  the  upper  strait  in  a  transverse 
or  oblique  direction ;  whether  the  back  is  in  front  or  rear,  it  is  not 
less  a  rare  thing  for  them  to  fail  to  place  themselves  in  an  antero- 
ppsterior  direction  in  the  excavation ;  being  strongly  pressed  against 
each  other  they  swell ;  in  boys,  the  scrotum  becomes  puffed  and 
infiltrated ;  as  they  curve  towards  the  pubis  to  gain  the  vulva,  they 
distend  the  perineum  almost  as  much  as  the  head  does,  the  form  of 
which  they  partly  simulate ;  they  are  next  seen  to  disengage  of  them- 
selves, and  then  every  thing  goes  on  as  in  a  footling  labour. 


SECTION  S. 
Of  the  Conduct  of  the  Accoucheur  during  Labour. 

799.  When  called  to  a  woman  who  supposes  herself  to  be  in 
labour,  there  are  two  ways  in  which  the  accoucheur  may  behave, 
accordingly  as  he  may  have  for  a  long  time  enjoyed  her  confidence, 
or  as  he  may  never  have  been  much  acquainted  with  her  before. 

In  the  former  case  he  should  examine  at  once,  in  order  to  ascer- 
tain whether  the  labour  has  really  commenced ;  in  the  latter,  it  is 
often  necessary  to  be  not  quite  so  much  in  a  hurry,  unless  indeed 
the  labour  seems  to  be  very  far  advanced. 

Ho  may  begin  to  talk  about  one  of  the  thousand  subjects  of  futile 
conversation  that  every  body  understands,  and  which  admits  of 
only  a  gradual  approach  to  the  principal  object ;  in  this  way  time  is 
allowed  for  quieting  the  agitation  commonly  occasioned  in  most 
women  by  the  presence  of  a  stranger,  and  particularly  an  accou- 


^M^* 


DIAGNOSIS.  329 

cheur ;  during  this  parley,  he  should  endeavour  to  possess  himself 
of  the  shades  of  character,  the  caprices,  tastes,  and  habits  of  the 
person  he  is  called  upon  to  direct,  in  order  to  adopt  such  a  plan  of 
conduct  as  is  most  likely  to  inspire  her  with  great  confidence  in  her 
attendant ;  the  subject  of  her  pregnancy  is  soon  brought  up,  the 
symptoms  that  have  accompanied  it,  the  peculiarities  that  have 
marked  it,  and  its  term  ;  he  may  ask  whether  she  has  had  several 
pregnancies,  or  whether  this  is  the  first ;  he  can  ask  about  the  gene- 
ral state  of  her  health,  the  inconveniences  and  diseases  that  she  has 
heretofore  suffered  ;  after  which  he  may  be  allowed  to  think  of  the 
labour  properly  so  called. 

§.  I.  Of  the  diagnosis. 

800.  Nothing  is  easier,  in  the  opinion  of  by-standers,  than  to  say 
whether  a  woman  is  in  labour  or  not ;  but  this  is  not  the  case  with 
the  well-instructed  physician.  As  women  in  their  first  child-birth 
lack  a  term  of  comparison,  they  very  frequently  deceive  themselves 
in  regard  to  the  sensations  they  experience ;  even  in  the  second, 
third  or  fourth  pregnancy  women  deceive  themselves  sometimes. 
How  often  have  the  neighbours,  relations,  the  widwife  or  accou- 
cheur been  seen  to  fix  and  arrange  every  necessary  preparation  for 
the  birth  of  the  child,  and  the  supposed  labour  cease  for  a  whole 
month  or  six  weeks,  just  when  the  bed  had  been  made  up  for  the 
reception  of  the  woman,  and  when  the  clouts,  the  ligature  for  the 
cord,  the  scissors,  the  caps  and  other  clothes  of  the  child  were  only 
waiting  for  the  arrival  of  the  stranger  to  be  applied  to  it !  How  often 
have  even  still  greater  mistakes  been  committed !  Who  does  not 
know  how  poor  women  have  been  kept  for  days  together  on  the 
child-bed,  even  by  physicians,  and  at  last  found  that  their  pregnancy 
was  several  months  off  from  its  close,  or  even  that  they  were  not 
pregnant  at  all !  A  young  woman  in  her  ninth  pregnancy  was 
seized  with  pain,  and  thought  herself  at  term  ;  several  accoucheurs 
were  called  in  succession.  One  said  that  the  bag  of  waters  was 
formed  ;  another,  that  the  head  was  about  to  engage  ;  a  third,  that 
he  could  not  find  the  os  uteri ;  a  fourth,  that  the  forceps  must  be 
applied.  This  poor  creature,  in  despair,  sent  for  me  on  the  fifteenth 
day  ;  I  found  the  cervix  as  it  is  at  the  seventh  month  ;  there  was  an 
anterior  obhquity  of  the  womb ;  I  stated  that  labour  had  not  begun, 
and  would  not  take  place  for  more  than  a  month — and  appHed  a 
broad  bandage  round  the  abdomen.  In  a  month,  a  student  who 
staid  by  her,  came  to  tell  me  that  the  os  uteri  was  dilated,  and  de- 
livery about  to  take  place.  I  repaired  to  her,  found  no  symptom  of 
labour,  and  in  fact,  the  child  was  not  born  till  a  month  afterwards. 

.       2  R 


330  DIAGNOSIS. 

When  persons  who  are  strangers  to  the  science  of  medicine  are 
deceived  in  this  way,  the  public  only  laugh  at  them  ;  but  what  con- 
fidence can  an  accoucheur  inspire  who  is  guilty  of  such  stupidity  ? 
It  imports  us  therefore  to  be  on  our  guard  against  such  causes  of 
error,  and  it  is  easy  for  those  who  have  any  positive  knowledge  in 
tokology  to  do  so. 

801.  The  pains  of  labour,  the  true  pains^  are  intermittent,  sepa- 
rated by  intervals  more  or  less  short,  progressive,  return  at  regular 
periods,  are  not  accompanied  with  tenderness  of  the  abdomen  nor 
heat  of  the  skin  nor  fever  ;  they  begin  in  the  neighbourhood  of  the 
umbilicus,  and  end  in  the  pelvis  or  flanks. 

Pains  foreign  to  labour,  false  pains^  are,  on  the  contrary,  vague, 
irregular,  sometimes  more,  sometimes  less  acute,  do  not  entirely 
cease,  increase  under  pressure,  and  are,  most  commonly,  accom- 
panied with  fever  or  some  kind  of  functional  disturbance ;  they  an- 
nounce a  lesion  of  the  stomach,  the  bowels,  the  liver,  the  kidneys, 
the  bladder,  or  some  other  organ  contained  in  the  abdomen,  and 
have  been  called  false  because  they  are  entirely  unconnected  with 
parturition,  appear  in  pregnant  women  as  they  do  in  those  who  are 
not  pregnant,  or  as  they  do  even  in  persons  of  the  other  sex. 
Nothing,  therefore,  but  the  greatest  want  of  reflection,  can  cause 
them  to  be  confounded  with  the  true  pains — those  which  depend 
upon  the  contractions  of  the  womb. 

802.  I,  however,  ought  not  to  omit  speaking  of  a  state  that  might 
render  this  discrimination  very  diflicult,  and  a  mistake  at  the  same 
time  liighly  dangerous :  if  an  inflamed  point  be  established  in  the 
neighbourhood  of  the  womb,  in  that  organ  itself,  in  the  bladder,  rec- 
tum, &LC.  just  as  labour  comes  on,  the  pains  of  child-birth  will  pro- 
gress just  as  those  of  the  disease  do,  and  if  it  were  absolutely  neces- 
sary to  decide  from  the  testimony  of  the  pains  alone,  the  most  skil- 
ful person  might  be  led  into  a  mistake.  But  the  science  possesses 
other  means  of  ascertaining  the  existence  of  labour.  If,  when  the 
sufiering  is  at  the  height,  the  hand,  placed  upon  the  hypogastrium, 
feels  the  womb  grow  hard,  contract,  and  become  rounder,  it  is  de- 
cided that  child-birth  is  about  to  take  place,  and,  in  this  case,  the  true 
pains  may  exist  alone,  as  they  may  also  be  met  with  in  conjunction 
with  false  pains.  If  the  hand  discovers  the  womb  to  be  unmoved, 
without  action,  and  without  connection  with  the  cries  uttered  by 
the  patient,  it  may,  to  a  certain  extent,  be  aflirmed  that  the  labour 
has  not  begun. 

803.  In  fine,  we  are  by  the  touch  enabled  to  solve  the  question 
without  any  fear  of  being  deceived.  While  ever  the  cervix  is  still 
un-eflaccd,  while  it  retains  some  few  lines  of  length  as  a  canal,  we 


DIAGNOSIS.  331 

may,  in  general,  assert  thai  the  woman  is  not  at  full  term  ;  only  we 
must  avoid  mistaking  the  lips  of  the  os  tineas  for  the  cervix  itself, 
and  remember  that  in  persons  who  have  had  several  lyings-in  before, 
it  is  now  and  then  found  to  be  extremely  soft  and  very  wide,  several 
days  or  even  several  weeks  previously  to  the  end  of  pregnancy  ;  and 
that  in  such  women  the  orifice  frequently  forms  a  cushion  or  an 
edge  several  lines  in  thickness  at  the  commencement  of  labour.  If 
it  be  a  first  labour,  the  cervix  does  not  begin  to  gape  antecedently 
to  the  appearance  of  the  true  pains,  and  if  it  feels  like  a  tubercle, 
pierced  through  its  centre,  we  may  be  satisfied  that  there  have  been 
as  yet  no  uterine  contractions  ;  where,  on  the  contrary,  it  is  thin,  like 
a  sharp  circle,  the  gestation  is  necessarily  at  itsHerm,  and  if  the  par- 
turition have  not  commenced,  it  is  almost  a  matter  of  certainty  that 
the  labour  will  not  fail  to  show  itself  within  a  few  days. 

To  obtain  a  decisive  proof  on  this  point,  we  have,  at  most,  only  to 
touch  during  a  pain  ;  if  the  finger  feels,  in  such  a  way  as  to  ad- 
mit of  no  doubt,  that  the  membranes  become  tense,  that  they  try  to 
engage  in  the  os  uteri,  which  manifestly  becomes  thinner,  contracts, 
or  opens  a  little,  to  return  immediately  afterwards  to  its  primitive 
condition,  nothing  further  is  wanting,  the  labour  has  began  ;  if 
nothing  of  all  this  is  observed,  we  may  be  content,  the  moment  for 
lying-in  has  not  arrived. 

804.  However,  I  cannot  quit  this  article  without  calling  the  at- 
tention of  young  practitioners  to  a  peculiarity  in  the  diagnosis,  that 
is  not  sufiiciently  known,  and  which  might  lead  them  to  deceive 
themselves,  after  what  has  been  above  said.  Modern  accoucheurs 
have  with  one  accord  rejected,  as  among  apocryphal  or  ill-under- 
stood facts,  the  very  numerous  cases  tending  to  prove  that  labour 
may  begin,  the  contractions  of  the  womb  be  brought  into  evident 
play,  and  that,  after  having  continued  for  several  hours,  the  labour 
may  be  suspended  so  that  delivery  shall  not  take  place  for  a  whole 
month  afterwards :  such  anomalies  as  these  have  been  cited  chiefly 
on  occasions  of  protracted  gestation,  and  as  proofs  of  superfoeta- 
tion  ;  it  has  been  pretended  that  such  powerless  efforts  as  the  above 
had  masked  the  natural  term  of  gestation,  and  that  the  time  that 
elapsed  betwixt  their  cessation,  and  the  real  labour,  was  an  excess' 
over  nine  months.  But  1  have  acquired  the  conviction  that  this  in- 
complete labour,  or,  as  Levret  calls  it,  false  labour^  is  not  a  mere 
chimera.  In  March  1824,  I  was  called  to  a  woman  in  the  rue 
d'Orleans,  in  her  second  pregnancy,  and  who  had  been  in  pain  for 
about  twenty-four  hours  ;  the  pains  were  regular,  weak,  and  sepa- 
rated by  pretty  long  intervals  ;  the  os  uteri,  which  was  very  soft, 
and  wide  enough  to  admit  of  the  introduction  of  three  fingers,  was 


332  DIAGNOSIS. 

not  completely  effaced  ;  the  point  of  the  ovum  had  already  begun 
to  engage  within  it,  and  when  the  pains  came  on,  the  membranes 
were  on  a  level  with  the  top  of  the  vagina,  and  became  smooth  and 
tense,  while,  on  the  other  hand,  I  felt  the  orifice  and  body  of  the 
womb  harden  and  contract  with  a  certain  degree  of  energy.  It 
was  ten  o'clock  at  night ;  I  announced  that  the  labour  would  not 
terminate  for  several  hours.  I  returned  home  after  giving  orders  to 
send  for  me  as  soon  as  the  waters  should  break  ;  not  being  sent  for 
the  next  day,  nor  the  day  after,  I  supposed  they  had  had  recourse  to 
the  advice  of  some  other  practitioner,  and  thought  no  more  of  it. 
Six  weeks  afterwards,  being  called  upon  again,  I  confess  I  was  sur- 
prised, for  I  supposed  the  woman  had  been  delivered  long  before. 
This  time  the  symptoms  persisted,  and  delivery  took  place.  M. 
Nivert  has  published  in  the  Clinique  des  Hopitaiix  a  case  of  the 
same  kind  which  he  met  with  at  my  amphitheatre.  MM.  Gerdy 
and  Tanchou  assure  me  that  they  have  witnessed  cases  nearly  simi- 
lar, and  I  have,  myself,  since  met  with  two  others. 

§.  II.  To  determine  the  position. 

When  the  existence  of  labour  is  no  longer  doubtful,  we  must  en- 
deavour to  learn  in  what  position  the  fcetus  presents. 

805.  The  vertex  is  in  general  easily  known  by  its  round  and  re- 
gular shape,  by  the  posterior  fontanel,  and  occipital  point,  by 
the  anterior  fontanel,  the  sagittal,  transverse,  and  lambdoidal 
sutures,  and  by  the  parietal  protuberances  ;  however,  when  the 
head  has  been  for  a  long  time  engaged,  the  teguments  occa- 
sionally form  so  large  a  tumour  upon  its  summit,  it  is  itself 
sometimes  so  elongated,  that  one  has  need  of  some  practice 
in  order  not  to  mistake  it.  It  is  in  many  cases  so  movable,  and 
particularly  so  high  up,  as  to  render  it  difficult  to  distinguish  it  with 
certainty  from  any  other  part.  As  long  as  the  membranes  remain 
unbroken,  we  ought,  besides,  not  to  try  to  reach  it  except  in  the 
absence  of  the  pains ;  otherwise  we  should  be  liable  to  rupture 
them  prematurely.  We  can,  therefore,  best  judge  of  the  presenta- 
tion of  the  foetus,  at  the  moment  when  the  waters  come  off:  the 
upper  oval  of  the  head  may  then  be  touched  throughout  its  whole 
extent ;  the  integuments  are  not  yet  swelled,  and  the  bones  have 
not  had  time  to  ride  over  each  other.  In  the  three  varieties  of  the 
occipito-anterior  position,  the  posterior  fontanel  approaches  more  or 
less  near  to  the  pubal  semi-circumference  of  the  pelvis,  and  is  be- 
hind one  of  the  acetabula  or  the  symphysis  pubis,  while  the  frontal 
fontanel  is  more  or  less  elevated  behind,  and  looks  towards  the  op- 
posite point  of  the  pelvic  cavity  ;  in  the  varieties  of  the  posterior 
position  the  fontanels  are  disposed  of  in  the  inverse  directions.    Al- 


DIAGNOSIS.  333 

though  it  approaches  very  near  the  centre  of  the  straits,  the  pos- 
terior fontanel,  notwithstanding,  almost  never  corresponds  to  it  ex- 
actly ;  both  in  the  anterior  and  posterior  positions,  this  fontanel  is 
always  placed  upon  a  much  lower  plane  than  that  occupied  by  the 
anterior  fontanel.  In  order  more  correctly  to  distinguish  the  dif- 
ferent varieties  of  the  vertex,  we  should  endeavour  to  recognize  the 
sutures  ;  by  adding  their  direction  to  the  notions  we  derive  from  the 
particular  situation  of  the  fontanels,  it  is  commonly  easy  to  avoid 
confounding  the  anterior  with  the  posterior  varieties,  and  to  attach 
to  each  shade  of  one  and  the  same  position,  those  characters  by 
which  it  is  separated  from  all  the  others. 

806.  The  face  is  so  different  from  every  other  part,  that,  at  a  first 
glance,  it  seems  impossible  to  mistake  such  a  presentation :  this  is  an 
error ;  the  proof  of  the  contrary  is  contained  in  all  the  collections  of 
cases, %nd  is  daily  met  with  in  practice  ;  the  chin  may  be  mistook  for 
the  elbow,  the  shoulder  for  the  heel,  or  the  knee  ;  the  mouth  for  the 
anus,  the  nose  for  the  sexual  organs,  and  the  cheeks  for  the  tube- 
rosities of  the  ischia.  Least  the  testimony  of  an  infinite  number  of 
learned  observers  should  not  sufiice  to  demonstrate  the  possibility  of 
such  mistakes,  I  will  relate  a  well  known  anecdote  of  a  former  pro- 
fessor of  midwifery  at  the  Ecole  de  Paris :  being  a  man  of  a  rather 
decided  character,  he  had  just  touched  a  woman  in  labour,  and  sup- 
posing he  had  found  a  face  presentation,  he  asserted  with  great  ges- 
ticulation that  such  a  position  could  in  no  case  be  confounded  with 
one  of  the  breech,  not  perceiving  that  his  finger,  which  was  covered 
with  meconium,  was  giving  him  the  lie,  in  the  faces  of  the  students, 
who  could  not  help  bursting  into  loud  laughter. 

It  is  chiefly  in  cases  where  the  soft  parts  of  the  face  have  had  time 
to  swell  and  pufi"  up,  that  we  may  be  readily  deceived,  especially 
when  the  mind,  pre-occupied  with  such  or  such  a  position,'  receives, 
with  a  sort  of  avidity,  the  most  equivocal  signs  as  certain  proof  of 
what  we  had  predicted.  With  proper  attention,  however,  we  shall 
be  enabled,  without  difficulty,  except  in  a  few  very  rare  cases,  to 
recognize  the  face  whenever  it  presents,  and  the  rupture  of  the 
membranes  allows  us  to  examine  it  naked  ;  the  eyes  and  eye  lids, 
the  nose  and  lips,  the  alveolar  arches  and  tongue,  the  chin  and  ears, 
which  are  found  near  at  hand,  possess  characters  too  decided  for 
the  positions  of  the  face  not  to  be  always  clearly  ascertained. 

807.  The  feet  cannot  deceive  the  accoucheur  when  they  pre- 
sent :  the  heel,  to  be  sure,  has  some  resemblance  to  the  elbow,  and 
the  toes  some  similarity  to  the  fingers  ;  but  when  we  remember  the 
diflference  of  length  between  the  latter  named  parts — that  the  one 
are  arranged  upon  the  same  line  and  short,  that  the  others  are  of 


334 


DIAGNOSIS. 


unequal  lengths  and  much  flexed  ;  when  we  reflect  on  the  form  of 
the  ancles  and  legs,  one  must  be  very  careless  to  compare  it  with  the 
fist  and  fore-arm,  and  not  to  distinguish  the  feet  from  the  hands,  ex- 
cepting when  these  parts  are  still  above  the  superior  strait. 

808.  The  knees  might  indeed  be  mistaken  for  the  elbows  or 
shoulders,  although  rounder  than  the  former  and  smaller  than  the 
latter.  But  as  two  elbows  cannot,  any  more  than  two  shoulders, 
present  at  once  at  the  strait,  we  may  be  sure  that  they  are  the  knees, 
from  the  mere  fact  that  there  are  two  such  tumours  together  in  the 
strait  at  the  same  time '',  and  as  a  single  knee  is  generally  accom- 
panied with  one  foot,  or  at  least  with  the  breech,  it  will  always  be 
easy  to  satisfy  ourselves  that  we  are  touching  some  part  of  a  lower 
extremity,  and  not  one  of  the  arms.  There  is,  notwithstanding,  one 
circumstance  that  seems  as  if  it  might  impose  upon  us  ;  I  mean  the 
simultaneous  presence  of  a  knee  and  an  elbow.  But  besides  the 
rarity  of  these  coincidences,  we  learn,  by  penetrating  a  little  further 
with  the  finger,  that  these  parts,  instead  of  approaching  towards  each 
other  at  their  origins,  separate  farther  and  farther  from  each  other. 

809.  Presentations  of  the  breech  have,  more  frequently  than 
others,  led  into  error  on  this  subject ;  where  the  buttocks  have  had 
some  difficulty  in  getting  through  the  os  uteri  or  the  strait,  they 
swell  like  the  vertex  ;  the  crease  that  separates  them  may  be  mis- 
took for  the  sagittal  suture  ;  the  coccyx  and  space  in  front  or  on 
the  side  of  it,  for  the  occipital  angle,  the  posterior  fontanel,  and 
lambdoidal  suture  ;  and  lastly,  the  ischia  may  be  mistook  for  the 
parietal  protuberances  ;  but  this  same  crease,  being  a  slit  and  not  a 
fold,  the  movableness  of  the  coccyx,  the  presence  of  the  anus  and 
of  the  genital  parts,  the  roots  of  the  members,  &c.  soon  bring  the 
accoucheur  back  to  the  knowledge  of  the  truth,  when  he  has  de- 
parted from  it  for  an  instant.  The  anus  and  genital  parts  might  be 
mistook  for  a  face  presentation,  were  we  not  to  remark  that  the 
mouth,  bordered  with  thick  lips,  contains  a  conoidal,  movable,  and 
fleshy  body,  the  tongue,  and  that  the  finger,  when  withdrawn  from 
the  rectum,  is  found  to  be  covered  with  meconium.  Still,  another 
circumstance  might  deceive  us.  I  shall  give  the  particulars,  because 
the  authors  have  omitted  to  mention  them.  Having  been  called 
upon  by  Madame  Lebrun,  the  midwife,  to  terminate  a  preternatural 
labour,  I  thought  I  could  feel  the  feet,  the  buttocks,  the  coccyx,  and 
anus  ;  but  my  finger  penetrated  into  an  opening,  bordered  by  thick 
lips,  at  the  bottom  of  which  I  felt  a  tubercle  similar  to  the  tongue. 
Disconcerted  by  this  combination  of  signs,  I  for  a  moment  thought 
I  had  to  deal  with  a  monstrous  child  ;  I  again  introduced  my  hand 
further ;  I  brought  down  the  feet,  and  the  emergence  of  the  hips 


DIAGNOSIS.  335 

soon  put  an  end  to  my  uncertainty.  It  was  the  vagina  that  I  had 
mistaken  for  the  mouth,  and  the  cervix  uteri,  vehich  is  very  salient 
at  that  age,  had  made  me  suppose  I  felt  the  tongue.  In  order  to 
obviate  all  hesitation  in  such  a  case,  it  is  merely  requisite  to  remem- 
ber that  the  mouth  is  open  behind,  so  as  to  be  continuous  with  the 
pharynx ;  whereas  the  vagina  ends  in  a  cul  de  sac,  at  the  bottom  of 
which  the  os  tineas  is  to  be  found,  in  the  shape  of  a  tubercle,  more 
rounded,  shorter,  and  particularly,  less  movable  than  the  tongue. 

§.  III.  Of  the  prognosis. 

810.  After  having  established  the  diagnosis,  a  new  question  natu- 
rally  presents  itself  to  the  mind  of  the  accoucheur,  while  it  is  very 
soon  propounded  to  him  also  by  the  patient  herself  or  her  attendants. 
Will  the  delivery  be  prompt  and  easy,  or  slow  and  difficult  ?  When 
will  it  take  place  ?  The  answer  here  is  an  extremely  delicate  mat- 
ter, and  ought  only  to  be  given  after  maturely  weighing  it,  and  then, 
with  the  greatest  reserve.  The  duration  of  labour  is  so  variable, 
depends  upon  circumstances  so  diverse,  and  sometimes  so  unex- 
pected, that  it  is  often  impossible  for  the  most  skilful  practitioner  to 
fix  it  beforehand,  even  approximatively.  On  the  one  hand,  it  would 
be  necessary  from  the  very  beginning  to  know  the  proportions  of 
the  foetus  and  pelvis,  with  how  much  energy  the  womb  shall  con- 
tract, and  how  often  the  pains  shall  succeed  each  other ;  on  the 
other,  he  ought  to  be  able  to  affirm  that  the  progress  of  the 
labour  shall  or  shall  not  be  interfered  with  by  a  hemorrhage,  an 
attack  of  convulsions,  a  prolapsion  of  the  cord,  or  some  other  acci- 
dent ;  that  the  fairest  and  best  position  shall  not  be  converted  to  an 
abnormal  one ;  that  the  membranes  shall  give  way  at  such  a  particular 
period,  and  not  at  any  other;  that  there  shall  or  shall  not  occur  a 
spasmodic  resistance  of  the  cervix,  &c.  Now,  none  but  ignorant 
women  or  impudent  quacks  can  pronounce  upon  all  these  points, 
and,  in  spite  of  so  many  uncertainties,  say  at  what  hour  the  labour 
is  to  terminate. 

811.  All  that  we  are  permitted  to  promise  in  a  general  way  is 
the  following  :  the  child  is  well  situated  ;  the  pelvis  is  neither  small 
nor  deformed  ;  the  genital  organs  are  healthy  and  well  disposed ; 
the  OS  uteri  soft  and  very  dilatable  ;  the  pains  occur  regularly  and 
with  constantly  increasing  force  ;  the  woman  is  courageous  and  well 
constituted  ;  therefore  the  termination  of  the  labour  will  be  prompt 
and  fortunate  :  a  little  less  prompt  if  it  be  a  first  labour  ;  a  little 
more  so  if  she  have  had  several  children  before,  and  still  more  so, 
even  too  rapid,  if  the  pelvis  be  possessed  of  excessive  amplitude. 
On  the  other  hand,  the  position  of  the  foetus,  without  being  posi- 


336  PROGNOSIS. 

lively  bad,  is  not,  however,  one  of  the  best,  or  perhaps  it  may  be  a 
very  large  one ;  the  pelvis  is  slightly  contracted  ;  its  axes  are  too 
much  or  not  sufficiently  inclined  ;  the  os  uteri  is  hard,  or  covered 
with  cicatrices ;  the  woman  is  of  a  delicate,  nervous,  or  lymphatic 
constitution  ;  in  all  these,  we  ought  to  fear  that  the  labour  may  be- 
come  a  long  one,  and  that  the  resources  of  art  may  become  neces- 
sary. We  can  also,  to  a  certain  extent,  judge  of  the  duration  of  the 
present  labour  by  her  former  ones,  and  particularly  by  the  effect 
produced  by  each  pain  upon  the  dilatation  of  the  os  uteri,  and  upon 
the  progress  of  the  foetus  through  the  pelvis.  In  fine,  when  all  the 
phenomena  occur  in  their  most  common  order,  we  may,  by  calcu- 
lating the  time  that  has  elapsed  since  the  first  pains,  tell,  within  a 
few  hours,  how  long  the  woman  has  still  to  suffer.  If,  for  example, 
only  two  or  three  hours  were  required  to  bring  the  dilatation  of  the 
OS  uteri  to  the  size  of  a  five  franc  piece,  it  is  extremely  probable  that 
not  more  than  that  will  be  necessary  to  complete  the  expulsion  of 
the  child  ;  but  this  is  the  highest  degree  of  precision  to  which  we 
can  pretend,  and  those  who  pique  themselves  upon  the  possession 
of  more  exact  knowledge  in  this  matter,  either  impose  on  the  public 
or  deceive  themselves. 

812.  The  accoucheur  who,  for  the  purpose  of  making  a  parade 
of  vain  knowledge,  thinks  himself  able  to  announce  the  precise  term 
of  delivery,  not  only  exhibits  his  own  ignorance  or  bad  faith,  but  he 
also  compromits  the  dignity  of  his  profession  and  the  safety  of  the 
woman.  If  indeed  it  be  true  that  chance  is  oflen  on  the  side  of 
impudence  and  quackery,  it  often  happens  that  the  predictions  of 
ignorance  or  rash  vanity  are  not  realized  ;  but,  if  promises,  gene- 
rally made  with  much  emphasis  and  assurance,  are  not  fulfilled  at 
the  appointed  time,  that  alone  is  enough  to  give  rise  to  the  liveliest 
solicitude,  in  the  minds  of  relations  or  assistants,  and  especially  in 
the  patient  herself,  who  never  fails,  afterwards,  to  think  either  that 
her  destruction  is  certain,  or  that  she  is  to  have  a  bad  labour. 

§.  IV.  Of  the  attentions  necessary  for  a  woman  in  labour. 

813.  Inasmuch  as  spontaneous  parturition  is  a  natural  function 
and  not  a  disease,  are  we  thence  to  conclude  that  the  Art  of  the 
accoucheur  is  unnecessary,  and  that  women  in  labour  have  no  need 
of  assistance  ?  Some  physicians,  misled  by  mistaken  philanthropy, 
have  thought  so.  In  animals,  say  they,  pregnancy  brings  no  incon- 
veniences, and  delivery  is  almost  unattended  with  pain.  The  wives 
of  the  Ostiacks,  who  are  still  strangers  to  the  refinements  of  Euro- 
pean civilization,  are  delivered  of  their  children  upon  the  spot  where 
they  happen  to  be,  and  immediately  resume  their  accustomed  occu- 


PROGNOSIS.  337 

pations,  or  continue  their  march,  if  they  happen  to  be  on  a  journey. 
Those  of  the  inland  of  Amboyna,  who  hve  under  a  directly  opposite 
temperature,  behave  in  the  same  way.     The  aborigines  of  certain 
countries  in  America  bathe  themselves  in  cold  water  and  return  to 
their  work  as  soon  as  the  child  is  born,  while  the  husband  goes  to 
bed  and  plays  the  patient  for  a  week  or  two !     Parturition  is  a  mere 
nothing  to  country  women,  who  cannot  spare  time  to  drag  them- 
selves, methodically,  from  the  bed  to  the  sofa,  and  vice  versa.  Who  has 
not  seen  soldiers'  wives  bring  the  most  robust  and  finest  children  into 
the  world,  without  in  any  respect  deviating  from  their  active  modes  of 
living,  or  without  ceasing  by  forced  marches  to  follow  their  regi- 
ments ?     Even  in  the  large  cities  it  is  not  uncommon  for  poor  wo- 
men to  go  on  foot  to  a  midwife  while  the  pains  are  upon  them,  and 
return  home  the  next  day  in  spite  of  Hygieine,  their  poverty  not  allow- 
ing them  to  attend  to  themselves  for  more  than  three  or  four  days. 
I,  like  Roussel,  have  seen  a  young  girl  who  found  means  to  conceal 
from  her  parents  both  the  humiliating  proofs  of  her  weakness  and 
the  operation  that  delivered  her  from  it.     What  practitioner  is  there 
who  has  not  had  an  opportunity  of  making  the  same  observation ! 
The  pregnancies  of  these  poor  creatures  being  illegitimate,  it  would 
seem  as  if  they  had  no  right  to  be  sick.     But  these  remarks  in  no 
wise  prove  that  women  ought  to  be  left  to  themselves  during  partu- 
rition.    In  the  first  place  it  is  false  to  say  that  parturition  in  animals 
never  requires  any  assistance,  and  is  never  accompanied  with  serious 
accidents  :  sows,  mares,  cows,  &c.  are  even,  in  general,  quite  ill  in 
bringing  forth  their  young,  and  country  people  are  by  no  means 
ignorant    of  the  fact.     Does   it    follow,    because    some    women, 
when  compelled  by  imperious  motives  to  dehver  themselves  in  pri- 
vate, or  without  taking  the  least  precaution,  escape  from  the  serious 
dangers  with  which  they  supposed  themselves  to  be  threatened,  that 
all  others  may  imitate  them  without  exposure  to  more  imminent 
perils  ?     If  there  are  some  whose  health  is  not  disturbed  by  such 
painful  experiments,  how  many  others  are  there  who  become  the 
victims  of  their  temerity  ?     Because  one  man  falls  from  the  top  of 
a  roof  without  breaking  his  bones,  does  it  follow  that  we  should 
advise  others  to  go  to  the  house  top  to  have  the  pleasure  of  tumbling 
down  to  the  ground  ?     Will  people  never  be  tired  of  referring  us 
back  to  a  period  of  primitive  nature,  that  every  body  talks  about, 
and   that  nobody  understands  ?      By  attempting   to  substitute  the 
exception  for  the  rule,  we  inevitably  fall  into  absurdity,  and  that  is 
what  happened  to  the  elegant  Roussel.     If,  in  order  to  avoid  the 
dangers  of  abuse,  it  were  always  necessary  to  forego  the  use,  what 
would  become  of  the  human  race  ?     The  business  of  the  accoucheur, 
2  S 


388  PROGNOSIS. 

doubtless,  is  not  to  put  himself  in  nature's  place  where  a  labour  is 
natural ;  but  somebody  ought  to  be  with  the  woman  who  is  able  to 
give  her  proper  directions,  to  foresee  accidents,  to  recognize  them, 
and  to  remedy  them  when  they  do  take  place  ;  to  apply  the  resources 
of  art  when  necessary,  and  at  the  opportune  moment ;  who,  by  the 
confidence  he  inspires,  calms  all  her  fears,  and  gives  courage  and 
resignation,  by  tranquilizing  her  in  regard  to  the  future  ;  but  who 
differs  more  and  more  from  the  mere  spectator,  in  proportion  to 
the  extent  of  his  knowledge  and  skill. 

814.  Hygienic  treatment.  The  chamber  and  every  thing  con- 
nected with  it  should  be  first  attended  to.  In  great  cities  a  back 
room  should  be  preferred,  or  the  quietest  and  best  aired  apartment 
of  the  establishment.  It  is  important  that  this  chamber  should  be 
sufiiciently  spacious,  well  lighted,  and  so  constructed  that  its  tem- 
perature may  be  easily  altered.  Too  great  a  degree  of  heat  would 
promote  sweats,  cerebral  congestions,  convulsions,  nausea  and  vomit- 
ings, to  which  women  are  already  but  too  much  predisposed  during 
the  efforts  of  labour ;  cold  would  not  be  less  injurious,  both  by  the 
disagreeable  sensations  it  would  be  sure  to  excite,  and  especially  by 
hindering  the  expansive  movements  of  the  fluids. 

816.  Odours,  even  the  sweetest,  are  also  not  without  inconve- 
niences. During  labour  the  nervous  irritability  of  the  woman  is 
generally  of  the  highest  grade,  and  the  senses  become  excessively 
excitable.  The  most  valuable  perfumes  are  sometimes  borne  no 
better  than  the  most  disagreeable  odours.  It  would  not,  for  exam- 
ple, be  always  safe  to  place  a  woman  in  labour  in  an  apartment 
filled  with  the  emanations  of  muse,  amber,  lilies,  orange  flowers,  or 
roses.  I  have  seen  a  lady  fall  down  insensible  and  with  convulsions 
upon  entering  a  room  containing  a  pot  of  reseda.  I  am  acquainted 
with  another  who,  without  being  pregnant,  is  seized  with  syncope 
or  lipothynia  whenever  a  fresh  rose  is  brought  near  her. 

816.  The  regimen  of  the  patient  requires  the  most  careful  super- 
intendence of  the  accoucheur ;  indiscretions  in  respect  to  it  may 
give  rise  to  the  worst  consequences.  In  regard  to  this  point,  atten- 
tion must  be  paid  to  the  probable  duration  of  her  sufferings,  to  her 
constitution,  and  habits :  if  the  delivery  may  be  expected  to  take 
place  within  from  four  to  six  hours  at  farthest,  all  kinds  of  aliment 
are  hurtful,  by  loading  the  stomach,  whose  digestive  power  is  tem- 
porarily suspended.  If,  on  the  contrary,  the  labour  progresses 
slowly,  she  may  have  broths  or  some  light  kind  Of  potage  ;  but  she 
ought  to  refuse  coffee  and  chocolate,  usually  preferred  by  women 
in  large  cities,  as  well  as  bread,  fruits,  vegetables  and  meats  of  every 
description,  which  are  best  liked  by  country  people ;  coffee  has  too 


HYGIENIC  TREATMENT.  339 

much  influence  upon  the  innervation,  and  circulation,  and  chocolate, 
bread,  and  meats  are  too  difficult  of  digestion  to  be  given  without 
some  fear  in  these  circumstances.  All  this,  however,  ought  to  be 
understood  only  in  a  general  way :  a  woman  who  is  healthy,  but 
rather  feeble  than  strong,  whose  digestive  organs  are  in  good  con- 
dition, may  without  inconvenience,  and  sometimes  even  with  ad- 
vantage, take  a  breakfast  of  coffee  or  chocolate,  at  the  commence- 
ment of  her  labour,  especially  if  she  has  been  long  in  the  habit  of 
using  them,  just  as  we  see  stout,  vigorous  country  women,  as  well 
as  robust  women  of  the  labouring  classes,  eat  one  or  several  cutlets 
without  being  at  all  incommoded  by  them.  It  ought  to  be  known 
that  these  exceptions  are  numerous,  for  by  proscribing  food  in  all 
cases  indiscriminately,  we  just  favour  the  evil  we  wish  to  avoid  ;  no 
matter  how  absolute  the  threats  of  the  accoucheur,  it  is  not  uncom- 
mon for  them  to  be  disregarded,  and  if  no  bad  consequences  follow, 
the  woman,  emboldened  by  impunity,  no  longer  submits  to  advice, 
relates  her  story  to  her  acquaintances,  and  as  all  beings  are  not 
less  alike  in  their  liability  to  illness  than  in  shape,  the  punish- 
ment of  her  indocility  fails  not  to  fall  upon  some  of  those  who  have 
had  the  imprudence  to  listen  to  her.  I  was  called  to  a  woman  in 
her  first  confinement,  in  the  month  of  March  1824:  this  lady's 
mother  had  had  thirteen  children  ;  she  had  never  omitted  to  drink  a 
bottle  of  wine  and  eat  one  or  two  cutlets  during  or  immediately  after 
her  travail ;  in  spite  of  my  remonstrances  the  daughter  must  follow 
her  example,  but  the  unfortunate  lady  expiated  her  mother's  impru- 
dences with  her  own  life !  We  must  therefore  allow  to  some  what 
we  would  rigorously  refuse  to  allow  to  the  far  greater  num"ber,  and 
content  us  with  laying  before  the  most  obstinate  the  dangerous  risks 
they  run,  and  then  leave  them  at  liberty  to  do  as  they  like. 

817.  Drinks.  Where  the  duration  of  a  labour  does  not  extend 
beyond  the  most  ordinary  limits,  the  woman  herself  is  pretty  often 
the  first  to  perceive  that  she  ought  not  to  eat,  that  food  would  do 
her  harm.  This  is  not  the  case  as  to  drinks  ;  the  excess  of  heat 
observed  during  the  strong  pains  has  the  effect  of  drying  the 
organism,  and  loudly  demands  the  introduction  of  fluids  into  the  in- 
terior. Those  that  may  be  allowed  are  innumerable  ;  the  infusions  of 
mallows  flowers,  of  marshmallow  roots,  of  linden,  of  violet,  of  buglass, 
and  borrage ;  decoctions  of  barley,  of  dandelion,  liquorice,  &c. 
either  pure  or  edulcorated  with  sirup  of  sugar,  gum,  honey,  capil- 
laire,  cherries,  or  marshmallows,  may  be  given  almost  without  distinc- 
tion, as  well  as  all  imaginable  ptisans,  provided  they  do  not  exert 
any  evident  action  upon  the  organism,  and  are  not  acid ;  for  it  is  the 
water  and  not  the  medicaments  that  is  here  demanded  by  the  organs. 


340  HYGIENIC  TREATMENT. 

Lemonade  and  acidulated  drinks  would  suit  as  well  or  even  better 
than  any  other  ;  but  the  stomach  does  not  bear  them  well  because 
they  increase  its  tendency  to  acidity.  Wine  and  water  produces 
the  same  effect ;  the  other  ptisans  often  diminish  the  thirst  very  little, 
particularly  if  the  woman  does  not  like  the  decoctions  of  barley,  dan- 
delion and  liquorice,  which  are  more  refreshing,  though  they  happen 
not  to  suit  or  be  agreeable  to  her  taste ;  if  pure  cool  water  is  taken 
with  more  pleasure  and  satisfaction,  I  see  no  reason  why  it  should 
be  refused  to  her,  taking  care  always  to  correct  its  crudity  with  a 
few  drops  of  orange  flower  water,  or  sirup  of  cherries  in  very  small 
quantity.  In  the  country,-  and  among  the  lower  classes,  where  the 
disembodied  relics  of  old  medical  doctrines  ordinarily  take  refuge, 
hot  wine  and  rotiesau  vin  sucre  are  still  given,  with  the  view  of  sus- 
taining her  strength,  and  eau  de  carmes,  and  a  hundred  other  more  or 
less  heating  compositions  to  accelerate  the  labour  whenever  it  ap- 
pears somewhat  tedious ;  but  these  incendiary  measures,  which  in- 
flame the  already  irritated  organs,  disturb  all  the  functions,  and  some- 
times excite  fever  that  no  means  is  capable  of  allaying,  and  pro- 
duce a  dreadful  hemorrhage  much  more  commonly  than  they  do 
any  good  in  hastening  the  delivery,  begin  to  go  out  of  fashion,  and, 
let  us  at  least  hope,  will  before  long  cease  to  enjoy  any  favour. 
Madame  Malville,  a  skilful  and  prudent  midwife,  was,  on  the  night 
between  the  20th  and  21st  of  January  1828,  called  to  a  poor  wo- 
man, and  though  all  the  phenomena  succeeded  each  other  with  the 
greatest  regularity,  all  she  could  do  was  insufficient  to  prevent  the 
administration  of  hot  wine ;  a  hemorrhage  came  on  ;  new  doses  of 
wine  were  taken ;  the  blood  flowed  still  faster,  and  wine  was  again 
given  to  obviate  the  faintness ;  the  child  nevertheless  was  expelled, 
but  a  frightful  discharge  took  place  immediately  afterwards ;  and 
but  for  the  coolness  and  firmness  of  the  midwife,  the  poor  creature, 
pale  and  exhausted,  and  unable  to  turn  her  head  upon  the  pillow 
without  falling  into  syncope,  must  have  inevitably  lost  her  life. 

It  is  only  in  cases  of  weakness  or  languor,  depending  upon  old 
diseases,  or  the  peculiar  constitution  of  the  woman,  that  it  is  oc- 
casionally found  useful  to  give  a  few  spoonfuls  of  good  red  or  white 
wine ;  but  there  must  be  no  counter-indication,  arising  from  the 
state  of  the  digestive  organs,  nor  a  state  of  excessive  nervous  exci- 
tability. 

818.  The  state  of  the  alvinc  and  urinary  excretions  will  also  re- 
quire the  attention  of  the  practitioner.  The  constipation,  which  is 
80  common  during  pregnancy,  causes  the  rectum  to  remain  inac- 
tive at  the  approaches  of  labour  ;  its  contents  may  prevent  the 
head  from  gliding  downwards,  irritate  the  sphincter  and  mucoug 


HYGIENIC  TREATMENT.  34 1 

membrane  in  the  neiglibourhood  of  the  anus,  occasion  too  violent 
a  straining,  and  promote  the  formation  of  hemorrhoids,  which  are 
naturally  of  too  common  occurrence  in  parturition.  Consequently, 
provided  the  woman  does  not  feel  the  necessity  of  going  to  the  close 
stool,  an  injection  of  a  decoction  of  marsh  mallow  root  or  flax 
seed,  or  simple  tepid  water  should  be  given. 

819.  Provided  no  discharge  of  urine  takes  place  before  the  head 
becomes  engaged  in  the  superior  strait,  the  emission  becomes  more 
and  more  difficult,  in  consequence  of  the  compression  which  the 
bas-fond  of  the  bladder  soon  suffers  ;  it  may  therefore  be  supposed, 
that  if  the  delivery  is  protracted,  the  retention  of  the  urine  may  be 
followed  by  a  painful  distension  of  the  bladder,  and  that  the  woman, 
who  is  restrained  by  the  fear  of  increasing  her  pain,  will  cease  to  bear 
down,  except  very  moderately.  The  action  of  the  abdominal  mus- 
cles, as  it  can  then  be  transmitted  to  the  womb  only  through  a 
stratum  of  fluid,  ceases  to  be  so  efficacious,  or  if  the  woman  gives 
herself  up  without  reserve  to  the  whole  force  of  the  exertions  she 
is  capable  of  making,  there  may  be  reason  to  fear  a  rupture  of  the 
bladder,  a  terrible  accident,  which  is  almost  necessarily  mortal. 

The  woman  should  therefore  be  advised  to  evacuate  the  bladder 
while  she  is  still  able  to  do  so,  and  if  the  natural  efforts  are  insuffi- 
cient to  effect  the  object,  the  catheter  should  be  employed  for  that 
purpose.  We  are  in  such  cases  sometimes  obliged,  in  consequence 
of  the  shortness  and  slight  curve  of  the  female  catheter,  to  make 
use  of  a  male  one  ;  but  if  we  take  care  to  push  the  fundus  of  the 
womb  backwards  with  one  hand,  whilst  we  try  to  introduce  the  in- 
strument with  the  other,  I  do  not  think  that  the  flat  catheter  which 
is  recommended  by  some  of  the  English  physicians,  can  ever  be  in- 
dispensably necessary. 

820.  The  period  of  labour  is,  without  contradiction,  one  in  which 
the  moral  state  of  women  demands  the  greatest  attention  ;  conse- 
quently, we  ought  with  all  possible  care  to  abstract  what  ever  may 
be  disagreeable  to  them,  or  likely  to  vex  them,  and  to  respect  even 
their  caprices  and  the  oddities  of  their  characters. 

None  should  be  permitted  to  remain  in  the  room  except  those 
persons  who  are  indispensably  necessary  ;  that  is,  one,  or  at  most, 
two  friends,  the  nurse,  and  accoucheur.  More  than  these  would 
render  the  air  impure  ;  some  could  not  bear  the  spectacle  of  suf- 
fering without  reflecting  the  impress  of  it  from  their  countenances  ; 
others  could  not  keep  their  tongues  still,  would  always  have  a  sup- 
ply of  stories  of  dreadful  cases,  and  a  thousand  imprudent  things 
to  say ;  at  one  while,  that  Mrs  such-a-one,  was  delivered  of  a 
monster,    or  neighbour    such-a-one,  died  with    convulsions ;    at 


342  HYGIENIC  TREATMENT. 

another,  they  delivered  Mrs  so-and-so  with  instruments^  &c. ; 
from  tenderness  or  real  interest  or  affectation,  they  grow  quite  sad, 
and  lament  over  the  possible  consequences  of  the  lying-in ;  and 
whisper  or  talk  in  a  low  tone,  or  at  least  they  sit  gloomy  and  silent, 
and  merely  throw  a  furtive  glancie  of  pity  towards  the  woman  in 
labour,  who,  as  she  is  almost  always  disposed  to  make  an  evil  inter- 
pretation of  all  that  is  said  and  done  about  her,  every  moment 
looks  for  her  sentence  of  death  in  remarks  only  half  heard,  in  ges- 
tures, or  in  the  expression  of  sadness  and  compassion  she  observes 
in  her  attendants. 

82 1 .  Parturition  is  a  function  that  seeks  the  shade,  that  may  be 
obstructed  by  indiscreet  looks,  and  which  as  far  as  possible  is  made 
a  mystery  of  by  modest  women.  The  accoucheur  ought  to  under- 
stand that  the  mother,  the  aunt,  grandmother  or  sister  are  not  always 
considered  as  the  most  agreeable  attendants  in  this  painful  moment. 
As  a  discreet  as  well  as  a  circumspect  and  prudent  interpreter,  he 
ought  to  dismiss  without  distinction  every  one  whose  presence  is  not 
desired  by  the  woman.  How  careful  should  he  be  himself!  impas- 
sible and  firm,  of  an  imperturbable  coolness,  he  must,  notwithstand- 
ing, know  how  to  compassionate  the  distress  of  which  he  is  a  wit- 
ness, encourage,  console,  amuse  ;  inspire  her  with  boundless  confi- 
dence and  great  familiarity,  by  the  affability  of  his  conduct,  by  rea- 
sonings that  every  body  can  understand,  by  his  patience,  the  amenity 
of  his  temper  and  the  gravity  of  his  manners  ;  he  should  be  able  to 
procure  obedience  without  constraint,  and  by  all  the  means  which 
are  suggested  by  moral  philosophy,  his  own  understanding  and 
education,  incessantly  combat  the  discouragement  and  dread  of  all 
sorts,  and  the  sadness  and  alarms  to  which  the  most  resolute  as  well 
as  the  most  timid  women  sometimes  give  way. 

822,  The  dress  of  a  woman  in  labour  was  formerly  a  matter  of 
great  consequence ;  there  were  gowns,  jackets  and  head  dresses 
devoted  to  this  purpose  alone  ;  every  country,  each  province,  and 
even  each  family,  had  its  peculiar  fashion  ;  a  woman  of  good  family 
would  think  she  could  not  lie-in  decently  without  her  gown  and 
other  lying-in  clothes  ;  at  present  these  old  customs  are  no  longer 
to  be  found,  except  in  a  few  countries  or  families,  where,  out 
of  a  mistaken  feeling  of  respect,  people  obstinately  resolve  not  to 
live  differently  from  the  mode  adopted  by  their  ancestors.  To  this 
the  accoucheur  has  nothing  to  say,  provided  the  form  of  the  dress 
and  its  arrangement  are  not  of  a  nature  to  interfere  with  the  free 
exercise  of  any  of  the  functions,  provided  there  be  no  constriction 
of  the  abdomen,  the  breast  or  the  neck,  that  the  motions  of  the 
limbs  arc  led  free,  that  the  materials  are  light,  neither  too  hot  nor 


HYGIENIC  TREATMENT.  343 

cold,  and  that  the  circulation  does  not  suffer  from  their  employ- 
ment. 

823.  The  bed  for  child-birth^  which  is  also  called  lying-in  bed, 
bed  of  labour,  bed  of  pain,  bed  of  misery,  little  bed,  &c.  is  also  a 
matter  of  fashion  or  custom,  which  has  singularly  varied  as  to  its 
form,  according  to  times,  places  and  whims.  There  are  some  wo- 
men who  will  not  make  use  of  them,  and  who  are  delivered  stand- 
ing up,  the  elbows  resting  on  a  mantel  piece,  the  back  of  a  chair, 
a  table,  a  bureau,  or  some  other  piece  of  furniture,  or  even  leaning 
on  the  shoulder  of  some  friend.  Some  women  place  themselves  on 
their  knees  upon  the  floor  ;  others  place  themselves  on  their  hus- 
band's knees,  with  their  legs  much  bent  and  elevated.  The  ancients 
made  use  of  a  peculiar  kind  of  seat  or  elbow  chair,  a  lying-in-chair^ 
having  supports  for  the  arms,  a  movable  back-piece,  with  notches 
in  a  piece  to  keep  it  at  different  degrees  of  elevation,  a  support  for 
the  feet,  and  a  pierced  seat ;  so  as  to  be  converted  at  will,  either 
into  a  real  bed,  or  an  arm  chair.  These  chairs,  still  made  use  of  in 
Germany  and  Switzerland,  and  very  good  drawings  of  which  may 
be  seen  in  the  works  of  Stein  and  M.  Hermann,  are  no  longer 
employed  in  France,  notwithstanding  M.  Rouget  has  lately  attempt- 
ed to  revive  them  by  presenting  to  the  Academy,  and  to  the  admin- 
istration of  the  hospitals  of  Paris,  a  new  lying-in  bed  of  his  own 
invention.  They  are  not  wholly  destitute  of  advantages,  but  as  they 
can  without  inconveniene  be  replaced  any  where  by  other  means 
more  common,  and  always  at  hand,  no  person  feels  the  necessity  of 
resorting  to  them  ;  and  it  would  be  too  ridiculous  to  see  a  surgeon, 
as  in  former  times,  always  followed  by  his  lying-in  bed,  when  pro- 
ceeding to  visit  a  woman  in  labour. 

824.  The  best  bed  is  one  with  a  sacking-bottom,  tight,  of  a  middling 
size,  and  so  placed  that  the  upper  end  may  rest  against  one  of  the  walls 
of  the  chamber,  and  leave  room  to  pass  conveniently  all  round  the 
rest  of  the  bed ;  one  mattress  is  laid  on  this  sacking-bottom,  and  a 
second  one,  bent  double  in  the  middle,  is  arranged  upon  it  in  such  a 
way  that  the  edge  of  one  of  its  extremities  may  support  the  buttocks, 
while  its  folded  portion  supports  the  back  and  head ;  a  piece  of  cloth, 
some  oil  cloth  or  some  cushions,  pillows  and  bolsters,  to  supply 
an  inclined  plane  for  the  head  and  breast,  complete  the  preparations. 

We  may  also  be  content  with  a  cushion,  to  be  slid  under  the 
middle  of  the  first  mattrass,  so  as  to  raise  the  pelvis  up  and  leave 
the  perineum  naked  ;  the  head  of  the  bed  is  then  formed  with  one  or 
two  common  chairs,  turned  downwards,  with  the  legs  against  the 
wall,  and  the  upper  edge  of  their  backs  towards  the  woman's  breech  ; 


344  HYGIENIC  TREATMENT. 

the  rest  of  the  arrangement  is  completed  as  before,  and  the  second 
mattress  is  not  wanted. 

A  single  mattress,  without  any  cushion,  will  also  answer  ;  it  is  to 
be  doubled ;  the  head  of  it  is  to  be  raised  with  chairs ;  all  that 
portion  of  the  sacking-bottom  that  is  to  be  in  front  of  the  pelvis  is 
left  uncovered,  and  by  means  of  some  cloths  to  receive  the  discharges 
upon,  we  may  avoid  soiling  any  part  of  the  bed  clothes.  Some  per- 
sons add  a  stick,  fixed  cross-wise  to  rest  the  feet  against  during  the 
expulsive  pains ;  but  this  fixture  is  more  troublesome  than  useful,  the 
hands  of  an  experienced  nurse  answer  much  better,  for  they  can 
follow  the  different  degrees  of  flexion  and  extension  of  the  limbs. 
In  the  country,  a  bed  is  often  made  by  placing  six  or  eight  chairs 
face  to  face  and  laying  a  mattress  upon  them. 

Indeed,  a  strong  and  well  formed  woman  may  be  delivered  in  any 
posture,  on  a  chair,  on  the  floor,  a  bundle  of  straw,  on  foot,  and  on 
all  the  kinds  of  beds  that  have  been  proposed ;  so  that  it  is  only  in  the 
cases  where  nothing  interferes  with  the  accoucheur's  prescribing 
just  what  he  thinks  best,  that  he  ought  to  attach  some  value  to  the 
composition  of  the  lying-in  bed  ;  further,  the  only  essential  matter 
is,  that  the  woman  should  be  as  comfortable  as  possible,  that  she  be 
not  incommoded,  neither  during  the  pains  nor  the  intervals  between 
them,  and  that  the  perineum  may  have  room  to  dilate. 

825.  There  is  not,  neither  can  there  be  any  fixed  period  at  which 
all  women  should  place  themselves  on  the  lying-in  bed  :  some  women 
feel  the  necessity  of  going  on  to  the  bed  as  soon  as  their  pains  get 
to  be  pretty  strong ;  others  not  until  a  much  later  period,  and  most 
women  may  be  guided  in  this  matter  by  what  agrees  best  with  their 
own  particular  feelings  ;  as  long  as  they  keep  on  the  bed,  or  on  foot 
either,  because  they  are  more  comfortable  in  either  case  respec- 
tively, and  not  for  the  sake  of  gratifying  some  preconceived  notion, 
they  ought  to  be  indulged  ;  it  would  be  absurd  to  compel  them  to 
remain  on  the  bed  from  the  beginning  to  the  end  of  a  labour,  while 
the  only  means  of  alleviating  their  distress  consists  in  moving  about 
from  place  to  place  ;  on  the  other  hand,  by  compelling  them  to  keep 
up  till  the  close  of  the  labour,  their  courage  and  strength  are  ex- 
hausted to  no  purpose,  they  are  exposed  to  the  danger  of  bringing 
on  flooding,  to  the  prolapsion,  and  overturning  of  the  womb,  lace- 
ration of  the  perineum,  and  to  the  too  prompt  and  precipitate  escape 
of  the  ftctus. 

Therefore,  in  regular  labours,  where  there  is  no  special  indication 
to  be  fulfilled,  it  is  useless  for  the  woman  to  lie  down  previously  to 
the  rupture  of  the  membranes,  unless  it  be  for  the  purpose  of  resting 


MANAGEMENT  OF  LABOUR.  345 

when  she  feels  fatigued.  When,  on  the  contrary,  the  dilatation  of 
the  OS  uteri  is  complete,  and  especially  when  the  head  has  descended 
into  the  excavation,  it  is  better,  but  not  always  indispensably  neces- 
sary, for  her  to  lie  down  on  the  bed  in  readiness  for  it.  Where  the 
pains  are  weak  and  far  apart,  and  where  the  membranes  give  way 
early,  or  the  head  remains  very  high  above  the  superior  strait,  and 
the  OS  uteri,  although  soft  and  very  dilatable,  opens  with  diffi- 
culty, she  ought  to  keep  up  and  move  about  as  long  as  her  strength 
will  permit.  Again,  she  should  be  persuaded  to  lie  down  early  if 
her  pelvis  be  a  very  large  one,  and  the  membranes  do  not  give  way, 
though  the  os  uteri  be  dilated,  when  the  labour  progresses  too 
rapidly,  and  when  there  is  a  threatening  prospect  of  hemorrhage, 
or  when  there  is  an  obliquity  of  the  womb.  Women  affected  with 
curvature  of  the  spine,  asthma,  hydrothorax,  ascites,  or  some  other 
abnormal  disposition,  are  sometimes  constrained  not  to  lie  down  at 
all,  and  are  obhged  to  be  delivered  while  standing  up,  or  seated,  or 
on  their  knees,  &.C.,  while  there  are  others  who  could  not  leave  their 
beds  before  the  termination  of  the  labour  without  difficulty.  But 
these  are  cases  of  exceptions  which  do  not  belong  to  the  class  of 
eutocia. 

826.  When  the  woman  is  on  the  bed,  she  should,  during  the 
pains,  be  on  her  back  with  the  legs  and  thighs  half  flexed,  and  the 
feet  resting  on  the  mattress  or  sacking.  This  posture,  which  is  so 
natural  that  women  assume  it  of  their  own  accord,  and  if  they  have 
changed  it  for  a  moment,  always  return  to  it  as  soon  as  the  pain  re- 
turns, is  particularly  necessary  where  the  womb  is  strongly  inclined 
forwards.  But  in  the  intervals  of  the  contractions  it  would  be  as 
ridiculous  as  it  would  be  cruel  to  exact  any  determinate  attitude  ; 
the  woman  ought  then  to  be  left  free  to  choose  a  position  that  is 
most  agreeable  to  herself,  on  either  side  ;  a  being,  when  suffering 
unavoidable  pain,  at  least  hopes,  by  changing  its  situation  and  trying 
various  positions,  for  some  alleviation  of  its  distress ;  to  deprive  it 
of  such  a  resource,  would  be  a  real  act  of  barbarity.  Moreover, 
the  attitude  on  the  back  is  very  rarely  necessary  except  in  cases  of 
very  decided  obliquity.  Most  of  the  English  and  American  women 
lie  on  the  left  side,  with  the  breech  near  the  right  edge  of  their 
common  bed,  which  is  properly  prepared,  the  legs  and  thighs  flexed, 
the  knees  separated  by  pillows  or  cushions,  and  notwithstanding,  we 
do  not  And  that  childbirth  is  much  more  dangerous  in  England  than 
in  France.  However,  it  is  evident  that  such  an  attitude  must  be 
very  uncomfortable  and  unfavourable  to  the  muscular  contractions 
that  occur  during  the  pains.  The  British  accoucheurs  who  recom- 
mend it,  think  it  admits  of  their  supporting  the  perineum  more  ef- 
2T 


346  EUTOCIA. 

fectually,  of  employing  the  touch  more  freely,  and,  which  I  cannot 
understand,  of  operating  more  readily  with  the  forceps,  the  hand, 
or  any  instrument  whatever ;  but  when  we  remember  to  what  extent 
the  modesty  of  the  English  ladies  is  carried,  and  reflect  on  their  ex- 
treme delicacy,  and  the  reserved  character  of  their  manners  and 
customs,  we  are  rather  led  to  think  that  the  lateral  position,  which 
prevents  them  from  looking  the  accoucheur  in  the  face,  has  been 
chosen  to  gratify  and  save  them  from  unpleasant  feelings. 

827.  The  accoucheur  places  himself  to  the  right  of  the  bed  ;  he 
is  there  most  commodiously  situated  to  touch,  to  follow  the  progress 
of  the  labour,  and  support  the  perineum;  all  of  which  may  be  done 
under  the  bed  clothes,  for  it  is  with  the  finger  or  hand,  and  not  with 
the  eye,  that  he  must  here  act  and  ascertain  the  state  of  the  parts. 
As  the  will  and  the  courage  of  the  patient  exert  a  great  influence  on 
the  progress  of  parturition,  it  imports  him  to  know  how  to  direct 
their  powers.  We  daily  meet,  in  practice,  with  women  who  hear 
dovm^  and  endeavour  to  make  the  most  of  their  pains,  as  soon  as 
they  become  somewhat  strong  ;  the  old  women,  the  midwife,  and 
sometimes  the  accoucheur  himself,  encourage  them  to  act  in  this 
way,  by  persuading  them  that  they  will  be  the  sooner  delivered. 
Such  conduct  is  extremely  blameable,  and  can  only  be  the  fruit  of 
ignorance  or  want  of  reflection.  Where  the  os  uteri  is  not  dilated, 
the  membranes  unbroken,  or  at  least,  where  the  head  is  not  as  yet 
engaged  in  the  superior  strait,  efforts  to  hasten  the  delivery  only 
serve  to  exhaust  the  woman  \o  no  purpose  whatever ;  until  the  end 
of  the  first  stage,  the  action  of  the  muscles  is  not  solicited,  the  womb 
does  not  demand  their  aid,  and  they  can  be  of  no  use. 

But  as  soon  as  the  fcetus  penetrates  into  the  excavation,  the  os 
uteri  being  dilated,  and  the  membranes  ruptured,  and  the  sense  of 
weight  about  the  fundament^  tenesmus,  and  strainings  are  felt,  they 
occasion  a  desire  to  hear  dovm^  and  compel  the  muscular  contrac- 
tions to  come  on  stronger  and  stronger  in  aid  of  the  womb,  in  pro- 
portion as  the  child  is  nearer  the  moment  of  expulsion.  The  womb 
now  compels  the  efforts  to  take  place,  independently  of  the  woman*s 
will;  the  thing  is,  to  know  how  to  make  the  best  use  of  them,  and 
there  are  many  women  who  do  not  know  how  to  do  it — who  do  not 
know  how  to  deliver  themselves ;  who,  with  the  expense  of  a  con- 
siderable degree  of  power,  cause  the  labour  to  advance  but  very 
little ;  the  accoucheur  should  teach  them  their  apprenticeship,  if  I  may 
use  such  an  expression,  should  teach  them  that  when  the  painS  are 
regular,  they  should  not  employ  their  voluntary  cfl^orts  until  the  con- 
traction is  fairly  begun,  or  until  the  muscular  action  is  positively 
solicited ;  then,  by  pressing  the  pelvis,  feet,  and  hands  upon  the  bed 


MANAGEMENT  OF  LABOUR.  347 

or  upon  the  persons  stationed  to  support  them,  they  should  bear  down 
with  all  their  miglit,  as  if  at  the  stool ;  as  soon  as  the  womb  itself 
ceases  to  act,  all  effort  ought  to  be  suspended,  and  the  woman 
should  be  strictly  directed  to  rest,  and  be  as  still  as  possible,  never 
losing  sight  of  the  fact,  that  the  muscles  are  not  intended  to  force 
the  foetus  downwards,  but  only  to  aid  an^  support  the  contractions 
of  the  uterus. 

828.  The  pains  are  sometimes  so  acute,  so  intolerable,  when  the 
head  reaches  the  inferior  strait,  that  instead  of  bearing  strongly  on 
the  pelvis,  and  pushing  downwards,  the  woman,  in  spite  of  her- 
self, draws  it  upwards  as  if  to  avoid  the  pain.  In  this  she  is 
doubly  disappointed ;  in  the  first  place,  because  nothing  can  save 
her  from  the  distress  she  endures,  and  because  she  in  this  way 
voluntarily  protracts  the  period  of  her  deliverance ;  and  then,  far 
from  being  an  evil,  violent  contractions  are  what  she  should  above 
all  things  desire,  for  upon  them  depends  the  prompt  termination  of 
the  labour.  The  same  thing  often  takes  place  in  women  who  are 
too  pusillanimous,  too  nervous  or  timid  ;  they  are  restrained  by  the 
fear  of  making  the  pains  too  sharp ;  they  are  restless,  and  toss  about 
from  place  to  place,  and  rather  than  assist  and  make  the  most  of 
their  pains,  do  all  they  can  to  hinder  or  suspend  them. 

829.  Some  of  them  fall  into  the  opposite  kind  of  excesses,  give 
themselves  up  to  such  immoderate  efforts,  that  unless  care  were 
taken,  very  serious  consequences  might  ensue,  such  as  a  great  con- 
gestion of  the  brain,  and  even  an  apoplexy,  the  sudden  sweHing  of 
the  thyroid  body,  and  the  rupture  of  the  large  veins  of  the  throat, 
the  formation  of  hernias  of  all  sorts,  temporary  paralysis  of  the  lower 
limbs,  &c.  The  dangers  to  which  they  expose  themselves  by 
inconsiderately  bearing  down  in  this  manner,  ought  to  be  painted 
in  strong  colours  and  exhibited  to  their  view,  and  all  the  means  of 
persuasion  and  controul  should  be  skilfully  employed  in  order  to 
oblige  them  not  to  give  way  so  completely  to  their  feelings.  If 
reason,  entreaty  and  gentleness  do  not  succeed,  a  firm  and  even 
menacing  tone,  properly  adapted,  sometimes  becomes  necessary. 
There  are  a  thousand  means  to  be  made  use  of  to  quiet  them,  to 
inspire  them  with  dread,  and  restrain  them.  Thus,  Baudelocque, 
after  having  in  vain  exhausted  all  his  resources,  thought  of  bringing 
two  lawyers  dressed  in  their  robes  into  the  chamber  of  a  woman  in 
labour,  by  which  she  was  so  intimidated  that  she  thenceforth  became 
reasonable,  and  submitted  to  the  counsels  of  her  accoucheur. 

830.  The  touch  is  performed  at  different  periods  of  labour,  for 
the  purpose  of  ascertaining  the  position  of  the  ftetus,  the  degree  of 
dilatation  of  the  neck,  and  to  learn  how  far  the  head  has  descended. 


Mcj^ 


aL<&  «<..-<^«d*. 


348  EUTOCIA. 

Rigorously  speaking,  it  would  be  sufficient  to  touch  three  times  dur- 
ing a  labour  :  once  at  the  commencement,  to  learn  certainly  whether 
the  womb  is  contracting  ;  a  second  time,  just  as  the  waters  break, 
to  make  ourselves  positively  sure  of  the  position  ;  and  a  third,  when 
the  pains  and  efforts  have  acquired  a  certain  degree  of  strength,  in 
order  to  see  whether  the  parts  engage  properly  in  the  excavation  ; 
but,  generally  speaking,  unless  the  vulva  and  vagina  are  very  sensible 
and  irritable,  we  may  repeat  this  operation  much  more  frequently, 
and  that  without  any  ill  effect.  Provide4  the  touch  were  never 
practised  but  for  the  purpose  of  learning  the  progress  of  labour,  it 
would  rarely  be  followed  by  any  other  inconvenience  than  that  of 
annoying  the  woman  and  wounding  her  scruples,  how  often  soever  it 
might  be  repeated,  always  excepting  the  cases  where  it  is  made  an 
object  of  study,  as  in  our  public  halls,  where  a  very  great  number  of 
students  touch  the  same  woman  in  succession.  But  there  are  ac- 
coucheurs who  resort  to  it  with  very  different  motives,  who,  furnished 
with  an  apron,  the  coat  off  and  shirt  sleeves  tucked  up,  seat  them- 
selves betwixt  the  woman's  knees,  and  perform  what  they  call  her 
lesser  labour,  and  forcibly  dilate  the  vulva  and  os  uteri,  under  the 
pretext  of  accelerating  the  progress  of  the  case.  The  poor  crea- 
tures who  submit  to  such  procedures,  and  are  even  the  first  to  ask 
for  them,  do  not  know  to  what  dangers  they  are  thereby  exposed. 
We  might  pity  those  who  put  them  in  practice  through  ignorance  or 
temerity,  but  what  ought  we  to  think  of  those  who  make  use  of  them 
as  a  system,  in  order  to  appear  more  skilful  and  important  in  the 
eyes  of  the  vulgar? 

831.  If  it  be  sometimes  useful  or  even  permissible  to  introduce 
one  or  more  fingers  into  the  vagina,  so  as  to  aid  in  the  dilatation  of 
the  parts,  it  is  only  in  cases  where  rigidity  or  an  irritated  condition 
of  some  point  in  the  vulvo-uterine  canal  indicates  that  it  would  be 
well  to  introduce  some  mucilage  or  soothing  ointment,  such  as 
Galen's  cerate,  or  the  cucumber  ointment,  and  not  oil,  as  recom- 
mended by  Consell.  When  the  head,  in  engaging  in  the  strait,  and 
even  in  passing  through  the  excavation,  pushes  the  cervix  before,  it 
like  a  cap,  there  may  be  some  use  in  supporting  the  circle  with  the 
end  of  one  or  more  fingers  during  the  pain  ;  but  if  it  is  not  always 
dangerous,  it  is  at  least  always  useless  to  try  to  overcome  its  resis- 
tance by  artificial  means. 

832.  To  support  the  perineum.  When  we  reflect  on  the  form  of 
the  pelvis  and  the  direction  of  its  axes,  it  is  easy  to  perceive  that 
the  perineum,  which  is  a  continuation  of  the  sacro-coccygeal  wall  of 
the  pelvis,  but  much  less  solid,  must  be  violently  distended,  and  run 
the  greatest  risk  of  being  torn,  as  the  head  emerges  from  the  lower 


MANAGEMENT  OF  LABOUR.  349 

strait.  Hence  all  accoucheurs  have  recommended  some  mode  of 
preventing  this  accident  from  taking  place.  Some  have  supposed, 
with  Mesnard,  that  it  is  only  necessary  to  push  the  coccyx  back- 
wards, or  to  place  two  fingers  between  the  head  and  perineum  when 
the  occiput  reaches  the  vulva  ;  others,  that  the  object  may  be  better 
attained  with  the  assistance  of  Roonhuysen's  lever,  or  a  wide  piece 
of  whalebone  ;  lastly,  some  practitioners  are  content  with  the  appli- 
cation of  the  hand  to  the  exterior.  But  inasmuch  as,  in  spite  of  all 
these  precautions,  the  perineum  sometimes  tears,  certain  modern 
surgeons  have  concluded  that  it  is  wholly  useless  to  support  it  in  any 
way.  If  I  can  give  credence  to  several  young  German  and  English 
physicians,  the  accoucheur  of  the  public  establishment  at  Gottingen, 
and  the  one  who  in  1824  directed  the  lying-in  hospital  of  Dublin, 
are  of  this  opinion,  and  I  am  assured  they  even  go  so  far  as  to  think  that 
the  precautions  recommended  on  this  head  are  all  dangerous.  As 
success  here  depends  less  upon  the  means  employed  than  upon  the 
hand  that  employs  them,  it  is  likely  that  a  long  time  must  elapse 
before  every  body  can  be  of  one  accord  as  to  the  value  of  those  that 
have  been  proposed.  , 

833.  However  this  may  be,  the  conduct  recommended  by  reason 
and  experience  is  the  following :  the  hand,  either  naked,  or  what  is 
better,  wrapped  in  a  linen  cloth,  is  applied  transversely,  so  that  its 
cubital  edge  may  correspond  to  the  point  of  the  coccyx,  and  that  its 
radial  edge  may  be  below  the  anterior  commissure  of  the  perineum, 
the  ends  of  the  fingers  may  lodge  betwixt  the  labia  and  the  thigh,  or 
extend  on  to  the  thigh,  while  the  finger  and  thumb  being  separated, 
are  placed  between  the  other  labium  and  opposite  thigh.  In  this 
way  we  convert  the  inclined  plane  that  the  head  has  to  pass  over  in 
emerging  from  the  soft  parts,  into  a  firm  wall ;  the  hand  is  placed 
there  as  if  to  continue  the  concave  surface  of  the  sacrum  and  coccyx, 
and  as  to  compel  the  head  to  adapt  itself  to  the  axis  of  the  vulva ;  the 
power  that  we  employ  must  therefore  act  from  behind  forwards,  from 
the  coccyx  towards  the  pudendum,  and  not  in  the  opposite  direction 
nor  laterally.  We  must  force  the  occiput  to  turn  upwards  towards 
the  pubis,  and  not  hinder  it  from  descending ;  besides,  it  is  only  at 
the  moment  when  the  head  begins  to  distend  the  vulva  with  a  cer- 
tain degree  of  force,  that  it  imports  us  to  act ;  previously  to  this 
period  the  operation  would  be  without  object,  and  the  accoucheur 
would  prove  merely  that  he  is  ignorant  of  its  mechanism.  By  trying 
to  bend  the  fingers  a  little,  as  has  been  recommended,  for  the  pur- 
pose of  bringing  the  soft  parts  towards  the  median  line,  the  hand  is 
rendered  too  concave,  and  does  not  support  the  head  sufficiently, 
and  we  thus  promote  exactly  what  we  wish  to  avoid  ;  by  placing  the 


350  EUTOCIA. 

hand,  as  others  recommend,  in  a  state  of  supination,  vertically,  with 
the  fingers  towards  the  coccyx,  and  the  wrist  towards  the  vulva,  we 
again  miss  the  object,  for  our  efforts  are  then  directed  with  more 
facility  in  front  than  behind,  while  the  contrary  is  what  we  wish  to 
do.  Finally,  to  prevent,  as  certainly  as  possible,  any  laceration 
from  happening,  we  may,  after  the  manner  of  M.  Flamant,  take 
hold  of  the  skin  on  the  buttocks  or  posterior  part  of  the  pelvis 
with  both  hands,  and  draw  it  forwards  as  much  as  possible ;  it  is 
proper,  it  is  even  important,  as  soon  as  the  parietal  protuberances 
have  passed  the  level  of  the  tuberosities  of  the  ischia,  to  engage 
the  woman  to  moderate  her  efforts,  instead  of  exciting  her  to  bear 
down  more,  and  more  as  is  too  commonly  done.  This  is  the  moment 
that  the  parts,  being  surprised  or  astonished,  are  lacerated,  if  the 
head,  pressed  too  rapidly  forwards,  does  not  give  them  time  to  yield 
and  mould  themselves  by  it.  Therefore,  the  slower  the  progress 
of  the  head,  the  greater  will  be  the  chance  of  preserving  the  peri- 
neum uninjured.  .  *. 

I  am  far  from  saying  that  laceration  of  the  perineum  is  in  all  cases 
a  serious  accident ;  on  the  contrary,  I  believe  it  to  be  very  rarely 
dangerous  ;  but  the  accoucheur  ought  nevertheless  to  do  all  he  can 
to  prevent  it  from  occurring  ;  and  I  cannot  too  strongly  condemn  the 
negligence,  in  respect  to  it,  of  which  most  of  them  are  culpable. 
If  it  be  not  in  our  power  to  prevent  the  woman  from  suffering,  it  is 
at  least  a  duty  to  preserve  the  natural  form  of  her  organs  as  far  as 
possible.  The  wound  will  heal  up,  no  doubt ;  but  the  dimensions 
of  the  external  orifice  of  the  vagina  remain  too  large,  and  we  cannot 
divine  what  distress  may  be  indirectly'  produced  by  this  accident, 
though  in  appearance  a  slight  one. 

834.  To  support  the  head  of  the  foetus.  As  soon  as  the  head  has 
passed  out  of  the  vulva,  it  should  be  supported  by  both  hands ;  the 
fingers  being  separated,  are  applied  under  the  occiput,  the  ear,  and 
lower  jaw  on  each  side,  being  careful  not  to  prevent  the  act  of  res- 
titution from  taking  place.  Rigorously  speaking,  we  might  dis- 
pense with  any  tractive  effort ;  for  the  remainder  of  the  fcetus  is 
oflen  expelled  with  the  same  pain  that  delivers  the  head  ;  or  else 
another  pain  soon  comes  on  to  complete  the  delivery  ;  however,  as 
there  is  no  advantage  to  be  derived  from  retarding  the  termination 
of  the  labour,  and  the  woman  has  nothing  so  much  at  heart  as  to 
be  promptly  delivered,  it  is  best  to  follow  up  the  impulsion  given  by 
the  womb,  and  whilst  it  is  still  contracting,  to  draw  very  prudently 
and  moderately  upon  the  head  or  armpits,  in  the  axis  of  the  inferior 
strait. 

The  conduct  I  have  just  above  indicated  is  particularly  applicable 


MANAGEMENT  OF  LABOUR.  351 

in  the  three  true  varieties  of  the  occipito-anterior  position.  It  may, 
and  indeed  ought  to  be  slightly  modified  in  most  of  the  other  pre- 
sentations. 

835.  Occipito-posterior  position.  When  the  occiput  looks  to- 
wards the  back  part  of  the  pelvis,  delivery  being  in  general  more 
difficult,  it  is  natural  that  we  should  profit  by  its  tendency  to  turn  for- 
wards, in  order  that  we  may  by  degrees  convert  it  into  an  anterior 
position,  in  which  we  may  sometimes  succeed  by  imitating  the  na- 
tural processes.  When  the  head  sinks  into  the  excavation  almost 
immediately  after  the  evacuation  of  the  waters,  we  endeavour  to 
make  it  deviate  to  the  right  or  left,  in  the  intervals  between  the  con- 
tractions, by  passing  two  or  three  fingers  up  in  front  of  the  sacrum. 
During  the  pain,  we  prevent  it  from  returning  to  its  original  posi- 
tion, by  leaving  the  fingers,  with  which  we  displaced  it,  betwixt  it 
and  the  median  line  ;  these  attempts  are  repeated  as  often  as  they 
may  be  deemed  necessary,  and  if  we  cannot  always  succeed  in  con- 
verting the  fourth  or  fifth  positions  of  Baudelocque  into  the  first  or 
second,  we  are  at  least  sure  that  we  occasion  the  mother  and  child 
both,  no  additional  hazard  where  the  maneuvre  is  properly  execut- 
ed. The  perineum  is  in  more  danger  of  being  lacerated  in  this 
than  any  other  position  ;  in  order  to  support  it  efficiently,  we  should 
take  care  not  to  incline  the  hand  too  much  forwards,  for  the  point 
of  the  head  would  fall  almost  perpendicularly  upon  it,  and  would 
rather  turn  backwards  towards  the  anus  than  glide  in  the  direction 
of  the  vulva.  This  is  the  situation  in  which  M.  Flamant's  precept 
is  especially  applicable. 

836.  Face  positions.  Although  the  face  positions  do  not  render 
delivery  much  more  difficult  than  those  of  the  vertex,  yet,  as  they 
are  less  exactly  according  to  nature,  it  is  always  prudent,  where  it 
appears  easy  to  do  so,  to  change  them  into  positions  of  the  vertex. 
It  can  no  longer  be  thought  of  after  the  head  has  once  reached  the 
excavation  ;  it  should  be  attempted  while  it  is  still  movable  at  the 
superior  strait,  and  that  in  two  different  ways  :  we  may  either  try, 
with  two  fingers,  to  push  the  chin  towards  the  breast  by  acting  on 
the  forehead,  or  we  may  endeavour  to  hook  the  occiput,  to  draw  it 
down  and  produce  the  same  effect.  In  both  cases  we  leave  the 
fingers  in  place  until  a  contraction  comes  on,  so  as  to  transfer  to 
the  occipital  branch  of  the  lever  represented  by  the  head,  the  power 
that  previously  acted  upon  the  facial  or  anterior  branch  of  it. 
It  would  be  particularly  important  to  effect  this  conversion  in  the 
mento-sacral  position,  if  it  should  ever  be  met  with.  Further, 
where  the  face  emerges  first,  it  is  not  so  easy  to  support  the  peri- 
nenm  as  it  is  in  the  vertex  positions ;  but  the  rupture  of  the  peri- 


352  EUTOCIA. 

neum  is  the  less  to  be  feared,  because  the  front  of  the  neck,  and- 
not  the  bregma,  presses  against  the  lower  edge  of  the  symphysis, 
while  the  upper  oval  of  the  head  passes  along  the  perineum  to  reach 
the  vulva.  The  hand  ought  therefore  to  press  but  moderately,  and 
not  at  all  until  the  forehead  is  without ;  otiierwise  we  might  in- 
crease the  danger  to  which  the  foetus  is  exposed,  or  at  least  inter- 
fere with  the  termination  of  the  labour. 

837.  Inclined  positions  of  the  Jiead.  When  the  whole  forehead, 
or  one  side  of  it,  the  anterior  fontanel^  one  of  the  parietal  protuber- 
ances, the  upper  part  of  the  nucha,  the  chin,  or  one  of  the  cheeks 
is  substituted  for  the  frank  vertex  or  face  positions,  they  do  not 
always  prevent  the  delivery  from  being  spontaneous,  because  the 
woman's  efforts  generally  succeed  in  causing  the  occiput  or  face  to 
descend.  Nevertheless,  as  these  intermediate  or  bastard  positions 
may  to  a  certain  extent  embarrass  the  progress  of  the  pains,  or  of  the 
labour  in  general,  we  ought,  as  soon  as  they  are  discovered,  to  attempt 
to  change  them  to  the  regular  positions  to  which  they  correspond. 
As  long  as  the  head  continues  at  the  superior  strait,  and  the  womb  .is 
not  too  strongly  contracted  upon  the  body  of  the  child,  we  might 
hope,  by  introducing  a  couple  of  fingers  behind,  in  front,  or  on  the 
sides  of  the  occiput,  to  bring  it  back  to  the  centre  of  the  strait,  or 
at  least,  if  we  could  do  no  better,  force  it  to  enter  fairly  with  the 
face  in  the  opening. 

838.  Positions  of  the  feet.  In  maintaining  that  footling  labours 
commonly  terminate  without  assistance,  I  did  not  mean  to  have  it 
inferred  that  we  must  never  touch  the  fcetus  in  any  way  until. )it  is 
completely  expelled  ;  but  merely,  that  it  is  unnecessary,  and  even 
dangerous,  to  exert  any  tractive  force  upon  it. 

As  soon  as  the  legs  appear,  they  should  be  supported,  after  wrap- 
ping them  in  a  napkin  ;  the  same  is  to  be  done  with  the  hips,  the 
arms,  the  breast  and  shoulders  ;  when  only  the  head  remains  in  the 
excavation,  we  place  a  couple  of  fingers  on  the  chin,  in  the  mouth, 
or  what  is  still  better,  on  the  sides  of  the  nose  ;  two  or  three  fingers 
of  the  other  hand  are  slid  under  the  symphysis  pubis,  sq  as  to  sup- 
port the  occiput,  and  as  soon  as  the  least  contraction  comes  on,  we 
draw  the  whole  downwards  in  the  direction  of  the  axes  of  the  in- 
ferior strait  and  vulva,  as  if  we  wore  trying  to  turn  the  child's  back 
up  over  the  mons  veneris,  and  upon  the  hypogastrium  of  ths^ 
mother.  ,  ^ 

839.  The  head  now  having  nothing  to  pass  through  except^iho 
perineal  strait,  is  beyond  the  influence  of  the  uterus,  and  may  be 
extracted  without  difficulty  ;  but  while  ever  it  has  not  traversed  the 
uterine  orifice,  or  the  abdominal  opening  of  tlic  pelvis,  the  least  at- 


MANAGEMENT  OF  LABOUR.  353 

tempt  to  accelerate  its  escape  could  tend  only  to  produce  a  case  of 
real  dystocia.  As  to  the  perineum,  it  is  easily  managed,  since  it  de- 
pends upon  the  accoucheur  to  pull  the  head  with  more  or  less  force, 
or  to  incline  it  more  or  less  forwards,  as  it  passes  through  the  vulva. 

840.  Positions  of  the  knees.  The  knees  present  very  few  pecu- 
liar indications  ;  if  they  present  in  a  regular  position,  they  should  be 
allowed  to  come  down  of  themselves,  and  when  they  reach  the  vulva, 
all  we  have  to  do  is  to  assist  in  disengaging  the  legs.  Ifoneof  them 
assumes  a  bad  direction,  lodges  against  some  part  of  the  pelvis,  or 
is  arrested  by  the  cervix  or  some  fold  in  the  vagina,  it  is  commonly 
disengaged  without  difficulty,  and  brought  alongside  of  the  other 
one.  For  the  remainder  we  are  to  act  as  in  feet  presentations, 
taking  care  not  to  pull  unnecessarily. 

841.  Positions  of  the  breech.  When  the  buttocks  descend  first, 
and  the  feet  tend  to  engage  at  the  same  time,  it  is  sometimes  well 
to  push  the  latter  back,  and  keep  them  somewhat  raised  during 
several  pains ;  if  not,  there  is  nothing  to  be  done  until  they  get  to 
the  bottom  of  the  excavation.  It  is  in  this  state  improper  to  pull  at 
the  breech  except  during  the  contractions  of  the  womb ;  if,  how- 
ever, its  size  is  very  great,  and  there  should  be  some  difficulty  in  its 
passing  through  the  vulva,  the  finger  hooked  into  the  groin  that  is 
towards  the  sacrum  may  be  of  some  service  by  enabling  us  to  give 
timely  assistance  to  the  woman's  eflTorts.  The  hips  are  scarcely 
delivered  before  the  constriction  they  had  experienced  is  transferred 
to  the  child's  belly.  It  is  important  then  to  pull  on  the  thighs  and 
legs,  which  should  be  extended  in  order  to  diminish  this  dangerous 
compression ;  the  management  of  the  rest  of  the  labour  is  in  all 
respects  similar  to  that  required  where  the  feet  or  knees  present. 
As  the  buttocks  are  escaping  from  the  inferior  strait,  they  sometimes 
distend  the  perineum  as  much  as  the  head  does  when  it  comes  first ; 
but  as  they  arc  much  softer,  and  the  flexibility  of  the  trunk  admits 
of  their  accommodating  themselves  much  more  easily  to  the  direc- 
tion of  the  axes  as  well  as  to  the  forms  of  the  spaces  they  are  ob- 
liged to  traverse,  they  much  more  rarely  occasion  a  laceration  ;  so 
that  in  such  cases  it  is  not  always  indispensably  necessary  to  support 
the  perineum. 

842.  In  oblique  positions  of  the  breech  we  must  act  as  in  the  in- 
clined positions  of  the  bead ;  we  must  endeavour  to  restore  them  to 
a  correct  state :  if  the  posterior  surface  of  the  coccyx  and  point 
of  the  sacrum  are  in  the  centre,  the  woman  should  be  directed  to 
lie  down  early ;  she  should  be  made  to  lie  as  much  as  possible  on 
the  back,  while  the  hand  applied  to  the  hypogastrium  pushes  the 
womb  backwards  and  upwards ;  if  this  precaution  should  not  suffice, 

2  U 


354  EUTOCIA. 

we  might,  with  a  couple  of  fingers  of  the  other  hand,  hook  the  ischia 
and  draw  them  down  into  the  strait.  If  one  of  the  buttocks  engages 
alone,  with  or  without  the  corresponding  hip,  it  should  be  raised  up 
during  the  absence  of  the  pains,  or  we  should  try  to  reach  it  directly, 
by  passing  some  of  the  fingers  up  along  its  external  surface. 

Where,  instead  of  one  buttock  or  the  coccyx,  we  meet  with  the 
genital  organs  or  fore  part  of  the  legs  in  the  centre  of  the  dilated 
OS  uteri,  it  is  generally  easy  to  bring  the  legs  down  in  place  of  the 
breech ;  and  this  ought  to  be  done  whenever  both  the  breech  and 
feet  present  at  the  same  time,  for  it  would  evidently  be  too  difficult 
to  compel  the  former  to  engage  alone. 

843.  Obliquities.  Anterior  inclination  of  the  womb  may  be  said 
to  be  the  only  one  that  demands  attention  during  labour.  When  it 
does  exist  the  fcBtus  always  engages  with  difficulty  ;  the  abdominal 
muscles  being  too  much  curved,  contract  with  but  little  energy ;  if, 
nevertheless,  the  child's  head  engages  in  the  excavation,  the  back 
part  of  the  cervix  rises,  while  its  fore  part,  which  becomes  thin  and 
distended,  covers  the  head  like  a  cap,  and  descends  beneath  the  strait. 

This  state  of  things,  moreover,  cannot  fail  to  embarrass  young 
beginners.  It  may  lead  them  to  suppose  that  the  dilatation  is  com- 
plete in  some  cases  where  it  has  scarcely  begun ;  finding  no  os  uteri, 
they  most  generally  begin  to  dream  about  anomalies,  or  else  know 
not  what  to  think  about  it.  Here  is  what  one  of  my  young  brethren, 
who  had  been  practising  in  the  capital  with  distinction  for  three 
years,  wrote  to  me  on  the  3d  of  January  1827.  "  I  have  been  all 
night  with  Madame  de  S.  A.,  the  labour  appears  to  go  on  regu- 
larly, but  I  cannot  find  the  os  uteri ;  I  have  passed  the  finger  up 
towards  the  promontory,  then  towards  the  iliac  fossae,  and  also  up 
behind  the  pubis  ;  at  all  these  places  I  have  reached  the  cul  de  sac 
formed  by  the  upper  extremity  of  the  vagina,  but  I  have  found  no 
cervix ;  what  must  I  do,  what  does  it  mean  ?"  The  truth  was  that 
the  orifice  had  gone  so  far  upwards  and  backwards  behind  the 
tumour  that  projected  into  the  excavation,  it  was  necessary,  in  order 
to  reach  it,  to  crook  the  finger  quite  forwards. 

Whenever  I  have  met  with  this  peculiarity,  which,  I  repeat  it,  is 
very  common,  the  labour  has  gone  on  very  slowly  until  the  end  of 
the  first  stage,  but  I  have  always  found  it  afterwards  to  progress 
with  much  energy,  and  to  require  no  particular  management. 

844.  Tedious  labour  In  former  times,  every  physician  and  every 
midwife  had  an  oxcytocic*  remedy,  some  sure  means  of  bringing 
labour  to  a  prompt  termination  ;  upon  this  head  all  the  arcana  and 

*  From  «^(/c  quick,  and  renot  child-birth. 


MANAGEMENT  OF  LABOUR.  355 

amulets  have  had  their  share  of  pliffs.  Some  put  a  bit  of  precious 
stone,  as  jasper,  topaz,  emerald,  &c.  in  a  small  bag,  which  was 
suspended  from  the  woman's  neck  ;  others  advised  her  to  hold  a 
piece  of  loadstone  in  the  right  hand  ;  sometimes  an  eagle's  plume 
was  fastened  to  the  thigh,  or  the  first  feather  of  the  right  wing  o 
that  bird  was  secured  to  the  sole  of  her  corresponding  foot ;  some 
times  again  she  was  to  have  the  belly  rubbed  with  viper's  fat  and 
snake's  gall,  or  the  navel  was  covered  with  a  very  hot  snake  or  rabbit 
skin ;  finally,  some  saffron  placed  on  the  hip,  some  cabalistic  sentence 
on  the  forehead  the  breast  or  pit  of  the  stomach,  and  a  thousand 
other  absurdities  of  the  same  kind,  were  also  frequently  made  use  of. 

As  M.  Desormeaux  remarks,  it  would  be  almost  puerile  to  make 
the  least  mention  of  such  nonsense,  provided  we  were  not  obliged, 
from  a  human  respect,  to  reply  to  certain  folks  who  hold  them  to 
be  great  secrets,  and  in  certain  cases  to  show,  like  Van  Swieten, 
some  condescension  for  the  weaknesses  of  females.  These  reme- 
dies at  least  will  do  no  mischief,  and  may  perhaps  prevent  the  ad- 
ministration of  some  less  inoffensive  remedy. 

The  aromatic  waters,  as  balm  and  mint  waters,  the  tinctures  of 
canella,  of  cloves,  all  sorts  of  compounds,  and  all  sorts  of  alcoholic 
elixirs  have  each  had  their  day,  and  many  women  who  used  them  have 
fallen  victims  to  their  imprudence.  Purgatives  and  emetics  have 
had  great  vogue  even  among  medical  men,  and  are  not  yet  wholly 
forgotten  by  the  vulgar.  Preparations  of  manna,  or  of  senna,  to 
which,  by  way  of  corrective,  was  added  lemon  or  orange  juice,  were 
very  much  used  in  the  time  of  Mauriceau ;  but,  without  denying 
that  such  preparations  may  possess  the  faculty  of  restoring  the  pains 
in  some  particular  cases,  and  without  fearing  their  action  on  the 
alimentary  canal  so  much  as  some  physicians  of  our  day  do,  it  is, 
notwithstanding,  manifest,  that,  if  they  ever  may  become  dangerous, 
it  is  chiefly  to  women  in  labour  that  they  are  likely  to  be  so. 

845.  Purgative  articles,  given  in  the  form  of  clysters,  are  not 
attended  with  the  same  disadvantages,  and,  in  fact,  they  appear  to 
have  been  employed  in  this  way  with  some  advantage;  amongst 
others,  the  decoction  of  senna,  whose  operation  is  generally  accom- 
panied with  smart  colic,  is  perhaps  not  to  be  wholly  neglected.  It 
is  at  least  certain  that  I  have,  at  the  Maternite  of  Tours,  seen  it  im- 
press upon  the  contractions  an  energy  that  could  scarcely  be  attri- 
buted to  mere  chance.  Bleeding,  baths,  antispasmodics,  opiates, 
borax,  and  many  other  articles,  are  in  the  opinion  of  some  persons 
possessed  of  very  decided  oxytocic  properties ;  but  in  order  not  to 
be  misled  in  this  manner,  we  should  be  careful  not  to  confound 
what  depends  on  time,  circumstances,  or  chance,  with  the  real 


356  EUTOCIA. 

effects  of  the  means  employed,  and  never  lose  sight  of  the  possi- 
bility of  those  singular  coincidences  which  often  put  to  flight  the 
most  skilful  combinations. 

846.  Labour  sometimes  progresses  with  extreme  slowness,  and 
may  last  from  two  to  five  or  even  eight  days,  without  there  being 
any  thing  particular  to  be  done,  and  that  in  two  opposite  cases: 
1.  In  young  nervous  women  at  their  first  lying-in,  and  who  are  of 
a  rigid  and  excitable  fibre ;  2.  In  those  of  a  delicate,  feeble  and 
lymphatic  constitution,  or  where  the  os  tincte  is  very  soft  for  some 
time  before  the  full  term.  In  the  former,  the  labour  can  with  diffi- 
culty set  in  fairly,  because  the  orifice  is  too  resisting,  or  of  too  great 
a  degree  of  sensibility  ;  here  a  small  bleeding,  if  warranted  by  the 
state  of  the  pulse,  and  the  strength  and  habitual  coloration  of  the 
patient,  a  tepid  bath,  unctions  with  belladonna  ointment,  and  slightly 
narcotic  and  soothing  drinks  may  sometimes  be  employed  with  advan- 
tage; in  the  latter,  it  seems  as  if  the  womb  were  in  a  state  of  uncer- 
tainty, as  if  it  were  assaying  its  strength,  as  if  under  the  necessity  of 
preparing  in  silence  before  entering  openly  into  action  ;  I  have  seen 
some  remain  two  three  or  four  days  in  this  state  ;  but  when  the  con- 
tractions once  acquire  a  certain  degree  of  energy,  the  labour  termi- 
nates in  general  with  an  extreme  rapidity,  which  singularly  contrasts 
with  its  former  slowness ;  indeed,  it  is  to  this  circumstance  that  a  crowd 
of  remedies  are  indebted  for  the  vogue  they  enjoy.  Nature,  here, 
has  no  need  of  assistance,  this  slowness  is  necessary  for  her,  and  it 
ought  not  to  be  disturbed  in  any  way ;  we  are  merely  permitted  to 
support  the  strength  by  giving  some  analeptic  aliments,  or  a  few 
spoonfuls  of  wine,  repeated  from  time  to  time,  and  always  with  the 
greatest  reserve. 

847.  On  other  occasions,  the  pains,  after  having  been  regular 
and  pretty  smart,  begin  to  return  only  at  long  intervals ;  sometimes 
this  is  owing  to  the  general  weakness  of  the  woman  or  the  fatigue 
of  the  womb ;  sometimes,  on  the  contrary,  it  must  be  referred  to  ill 
directed  efibrts  of  the  womb,  or  to  its  not  possessing  a  great  share 
of  excitability.  In  the  former  case,  rest,  and  some  broth,  if  there  be 
any  appetite,  a  little  wine  if  there  be  not  too  much  thirst  and  heat, 
and  resignation,  are  all  that  we  can  recommend.  In  the  latter,  we 
also  recommend  rest  if  the  woman  is  much  fatigued,  but  otherwise 
she  should  be  advised  to  walk  about ;  for  it  cannot  be  denied  that 
walking  about  and  a  vertical  posture  positively  accelerate  the  pro- 
gress of  labour. 

Time  and  patience  are  here  the  great  remedies  ;  but  this  is  a  sad 
resource  for  one  who  is  in  a  state  of  suffering,  and  the  accoucheur 
must  expect  the  most  multiplied  solicitations,  and  all  sorts  of  proposals 
and  entreaties  from  all  the  by-standers.     As  long  as  they  are  satis- 


MANAGEMENT  OF  LABOUR.  357 

fied  with  amulets  and  inert  topical  applications,  and  do  not  insist  on 
giving  active  substances  internally,  they  should  be  allowed  to  say 
and  do  as  they  like ;  it  is  one  way  to  amuse  the  women  ;  while  they 
see  us  busy  in  regard  to  their  sufferings,  they  bear  them  more  cou- 
rageously. Should  the  practitioner  be  compelled,  for  the  sake  of 
quiet,  to  prescribe  some  remedy,  he  should  follow  the  advice  of  Mau- 
riceau,  and,  in  the  first  place,  make  a  bargain  with  the  patient,  obtain 
from  her  as  much  time  as  possible,  and  promise  her  that,  if  at  such 
an  hour  the  pains  do  not  return,  he  will  then  cause  them  to  begin 
again ;  then,  when  the  hour  agreed  upon  arrives,  if  the  pains  continue 
to  be  still  weak,  take  care  that  the  article  to  be  made  use  of  cannot 
be  procured  except  from  some  considerable  distance  ;  that  the  per- 
son sent  to  bring  it  be  a  dull  messenger,  who  will  be  apt  to  lose  his 
way ;  let  it  be  some  sort  of  wood,  or  bark,  or  root,  or  at  least  some 
hard  substance.  When  the  remedy  at  length  arrives,  it  must  be 
pulverised  or  rasped  for  a  long  time ;  after  which  it  should  be  boiled 
for  several  hours.  In  the  next  place  the  liquid  must  have  time  to 
cool ;  it  is  next  passed  through  a  piece  of  linen,  something  more  is 
to  be  added,  and  then  it  should  be  boiled  over  again ;  at  last  it  is 
given  to  the  patient,  and  as  three  or  four  hours  are  necessary  for  it 
to  produce  its  effect,  it  is  easy  to  see  that  we  may  in  this  way  gain 
more  than  half  a  day,  and  that  within  that  interval  the  pains  will 
rarely  fail  to  resume  their  natural  course. 

848.  In  certain  cases  the  labour  becomes  slow,  because  the  con- 
tractions are  difficult,  extremely  painful,  unequal  or  partial.  The 
first  mentioned  case  ordinarily  depends  upon  plethora,  either  local 
or  general,  which  is  the  cause  why  the  uterine  fibres,  engorged  with 
blood,  and  as  it  were  stupified,  cannot  contract  with  suitable  energy ; 
women  who  are  strong,  robust,  sanguine,  and  very  muscular,  are 
most  liable  to  this  state  of  things,  which  is  known  by  a  feeling  of 
general  uneasiness,  weight  and  distress  felt  in  the  hypogastrium  and 
pelvis,  a  highly  coloured  skin,  and  especially  by  the  pulse,  which  is 
either  strong  and  large,  or  contracted,  small  and  hard ;  in  this  case, 
bleeding  from  the  arm,  by  means  of  the  depletion  it  occasions,  fre- 
quently succeeds  in  restoring  to  the  pains  all  necessary  activity. 

The  second  case  may  be  met  with  alone,  or  concurrently  with 
the  former:  and  as  its  cause  is  an  exalted  sensibility,  whether 
natural  or  accidental,  of  the  whole  economy,  or  of  the  sexual  organs 
in  particular,  it  is  proper  after  bleeding,  if  that  has  been  deemed 
useful,  to  have  recourse  to  baths,  to  the  mildest  anodynes,  and  even 
to  the  thebaic  preparations. 

The  third  case  is  of  much  more  frequent  occurrence  than  the 
generality  of  practitioners  suppose,  and  I  can  hardly  comprehend 


358  EUTOCIA. 

why  the  authors  make  scarce  any  mention  of  it  in  the  treatises  put 
into  the  hands  of  students.  The  work  of  Wigan,  which  is  highly 
esteemed  in  the  north,  proves  that  these  contractions  have  fixed  the 
attention  of  the  German  accoucheurs  in  a  very  special  manner : 
among  us  hardly  any  body  but  Madame  Boivin  speaks  of  it ;  but 
Burns  and  Dewees  treat  it  somewhat  more  at  length.  Sometimes 
it  is  the  fundus  of  the  womb  that  contracts  thus  spasmodically, 
while  the  rest  of  the  organ  hardly  contracts  at  all  ;  sometimes, 
again,  it  is  one  of  its  angles,  a  portion  of  its  anterior  wall,  of  its 
posterior  wall,  or  one  of  its  sides  ;  the  pains  are  not  less  acute 
than  they  would  be  if  the  whole  organ  contracted,  they  may  even 
be  more  severe,  but  they  are  in  pure  waste,  or  at  least,  far  from 
having  as  much  influence  on  the  progress  of  the  labour  as  the  re- 
gular contractions.  If  the  parietes  of  the  belly  are  not  too  thick, 
we  can,  by  applying  the  hand  upon  the  hypogastrium,  feel  that  the 
uterine  ovoid  is  not  even,  that  there  are  lumps  or  inequalities,  and 
that,  too,  independently  of  the  form  of  the  foetus.  Wigan,  who  gives 
to  this  disposition  the  appellation  of  tetanus,  appears  to  me  to  have 
made  too  many  divisions ;  practice  can  derive  no  benefit  from  it, 
and  theory  gains  by  it  nothing  but  confusion. 

Whenever  the  general  state  of  the  patient  does  not  contra -indi- 
cate it,  we  must  here  also  have  recourse  to  bleeding,  then  to  baths, 
and  next  to  simple  anodynes,  diffusible  anti-spasmodics,  opiates, 
&c.  I,  for  example,  use  with  success  a  potion  composed  in  the 
following  manner:  B  lettuce  and  wild  poppy  water  3  iv,  orange 
flower  or  mint  water  3j,  syrup  of  pink  or  white  poppies  3j,  or  syrujp 
of  marsh-mallows,  3j,  with  extract  of  opium  gr.  i,  or  laudanum,  from 
grs.  V  to  grs.  x.  Simple  frictions  on  the  belly,  long  continued,  also 
succeed  pretty  often.  They  are  sometimes  performed  with  the  hand 
alone,  or  with  a  flannel,  either  dry  and  hot,  or  wet  with  oil  of  chamo- 
mile, camphorated  alcohol,  or  cologne  water,  &c.  Although  nature 
herself  frequently  succeeds  in  restoring  the  natural  order  of  things, 
this  state  is,  notwithstanding,  not  to  be  overlooked,  in  the  first  place, 
because  it  indefinitely  prolongs  the  labour,  and  in  the  next  because 
it  may  be  looked  upon  as  a  morbid  state,  or  at  least  as  evidence  of 
great  predisposition  to  diseases,  or  to  inflammation  of  the  womb. 

849.  Spasmodic  contractions  of  the  os  uteri  have  also  been  ob- 
served, and  I  have  several  times  seen  its  dilatation  completely  ar- 
rested, or  considerably  retarded  for  hours  together  by  this  irregu- 
larity, which  in  general  requires  the  same  treatment  as  the  preced- 
ing. In  some  instances,  the  os  uteri  is  at  the  same  time  very  sensi- 
ble, dry,  hot,  highly  irritated  and  painful,  although  regular  in  shape; 
a  valuable  remedy  in  such  a  state  of  things,  and  far  more  efficacious 


MANAGEMENT  OF  LABOUR.  359 

than  hip  baths,  and  emollient,  mucilaginous,  or  narcotic  injections, 
or  various  sorts  of  ointments  usually  recommended,  is  found  in  the 
belladonna  ointment,  proposed  by  Chaussier  and  Dr  Conquest,  and 
frequently  made  use  of  by  Madame  Lachapelleat  the  Maison  d' Ac- 
couchement at  Paris.  Its  employment  too  is  followed  with  no  incon- 
Tenience  :  when  I  have  occasion  for  it,  I  direct  one  drachm  of  the 
juice  or  extract  of  belladonna  to  be  triturated  with  one  ounce  of 
cerate  or  hog's  lard  ;  with  the  fingers  I  easily  introduce  a  portion 
of  this  ointment,  as  large  as  a  filbert,  up  to  the  os  uteri,  the  whole 
circumference  of  which  is  soon  anointed  with  it.  The  belladonna 
acts  here  as  it  does  upon  the  iris,  when  applied  betwixt  the  eye  lids 
a  few  hours  previously  to  performing  the  operation  for  cataract,  and 
often  with  a  promptitude  that  is  really  surprising. 

In  the  spring  of  1 825,  a  young  woman  of  good  constitution  was  seiz- 
ed with  labour  pains  at  five  o'clock  in  the  evening ;  the  labour  went 
on  regularly  all  night.  The  next  morning,  at  six  o'clock,  the  os  uteri 
was  as  large  as  a  three  livres  piece  at  least ;  from  that  time  the  dilata- 
tion progressed  slowly,  although  the  force  of  the  pains  did  not  di- 
minish at  all ;  a  vein  was  opened  in  the  arm  ;  the  agitation  of  the 
patient  went  on  increasing,  and  the  orifice  continued  in  nearly  the 
same  state.  M.  Ribail,  who  had  the  care  of  the  woman,  sent  her 
to  the  hospital,  where  I  saw  her  at  half  past  six  in  the  evening :  the 
OS  uteri  was  a  little  larger  than  a  five  franc  piece,  and  formed  a  thin 
circle,  almost  sharp,  hot,  and  extremely  sensible ;  the  pains  still 
continued ;  the  ointment  was  applied  at  seven  o'clock,  and  before 
the  clock  struck  eight  the  delivery  was  completed. 

Conclusive  as  was  this  result,  it  nevertheless  appeared  to  me  dif- 
ficult to  attribute  it  exclusively  to  the  action  of  the  ointment,  but 
since  then  I  have  used  it  in  five  different  cases,  and  in  all  of  them 
the  efiect  has  been,  if  not  altogether  as  prompt,  at  least  quite  as  un- 
deniable. 

850.  I  have  elsewhere  said  in  what  manner  the  premature  rup- 
ture  of  the  membranes  or  their  too  long  continuance  in  an  unbroken 
state,  might  retard  a  labour  or  render  it  a  bad  one.  In  the  former 
case  we  ought  to  do  every  thing  in  our  power  to  favour  the  dilata- 
tion of  the  orifice  without  increasing  the  power  of  the  uterine  con- 
tractions, for  it  is  important  to  relieve  the  foetus  as  soon  as  possible 
from  the  dangerous  compression  it  has  to  suffer  ;  to  fulfil  this  indica- 
tion, it  appears  to  me  to  be  proper  to  direct  the  woman  to  walk 
about,  to  moisten  the  parts  in  some  way,  and  especially  to  have  re- 
course to  the  ointment  of  which  I  have  just  been  speaking. 

In  the  latter,  that  is,  where  the  point  of  the  ovum  is  too  slow  in 
giving  way,  it  must  be  ruptured.     To  be  done  without  inconveni- 


360  EUTOCIA. 

ence,  this  little  operation  requires  the  combination  of  the  following 
conditions  :  1 .  That  the  dilatation  shall  be,  at  least,  very  much  ad- 
vanced ;  2.  That  the  pains  shall  be  maintained,  without  any  threat- 
enings  of  inertia ;  3.  That  the  child  shall  be  in  a  good  position  ; 
and  4.  That  there  shall  be  no  other  obstacle  to  the  delivery. 

851.  Should  the  os  uteri  not  be  largely  dilated,  we  should  be  ex- 
posed to  the  inconveniences  connected  with  a  premature  rupture  of 
the  membranes  ;  if  the  womb  should  cease  to  contract,  or  contract 
only  a  little,  we  might  give  rise  to  complete  inertia  and  all  its  con- 
sequences ;  were  the  foetus  badly  situated,  we  should  increase  the 
dangers  of  the  presentation,  and  should  the  resources  of  art  become 
necessary,  their  application  would  be  far  less  easy.  But  it  should 
be  well  understood  that  these  general  rules  are  not  without  excep- 
tions :  for  instance,  where  the  fluid  enclosed  in  the  amnios  is  in  too 
large  quantity,  it  may  be  allowed  to  escape  even  although  the  open- 
ing of  the  cervix  is  not  considerable  ;  the  same  holds,  too,  where 
the  position  of  the  child  is  not  fixed,  where  the  hips,  shoulders,  head, 
or  any  other  part  is  found  to  present  by  turns  at  the  centre  of  the 
strait.  In  this  case  we  seize  the  moment  when  the  head  is  well 
situated  to  rupture  the  membranes,  because,  were  this  rupture 
left  to  nature,  it  might  as  well  take  place  while  it  is  unfavour- 
able as  while  the  position  is  favourable.  Where  the  bag  of 
waters  does  not  retain  the  shape  of  a  segment  of  a  sphere,  is  very 
much  elongated,  or  pyriform,  its  presence  being  no  longer  of  any  use 
as  to  the  progress  of  the  dilatation,  it  should  be  broken  witliout  too 
much  regard  to  the  degree  of  the  dilatation.  The  same  principles 
guide  us  in  respect  to  the  strength  of  the  pains  ;  their  absence 
ought  not  always  to  deter  us,  for  the  rupture  of  the  membranes  is 
often  the  best,  and  sometimes  the  only  means  of  restoring  them. 

862.  To  effect  this  rupture  there  are  a  thousand  different  modes 
of  proceeding  :  the  point  of  a  bistoury,  of  a  pair  of  small  scissors, 
of  a  common  sewing  needle  or  a  knitting  needle,  of  a  pin,  directed 
by  the  pulp  of  the  fore  finger,  has  often  been  found  suflicient,  and 
perhaps  been  employed  with  advantage  ;  for  one  must  be  very  un- 
skilful or  careless  seriously  to  wound  the  mother  or  foetus  with 
either  of  those  instruments  ;  however,  at  the  present  day  we  proceed 
generally  in  a  different  manner :  the  membranes  are  scratched 
through  with  the  finger  nail,  while  they  are  tightly  stretched  ;  or  we 
endeavour  to  burst  them  with  the  end  of  the  finger  by  suddenly 
pushing  upon  the  tumour  from  its  point  towards  its  base  ;  and  if 
the  first  attempt  does  not  succeed,  we  make  a  second,  a  third,  &.c. 
always  during  the  height  of  the  pain  ;  or  again,  and  the  method  is  a 
better  one,  we  firmly  pinch  a  fold  of  the  membranes,  while  in  a 


MANAGEMENT  OF  LABOUR.  361 

s^e  of  relaxation,  and  in  such  a  way  that  the  next  contraction  of 
the  uterus  in  essaying  to  form  the  bag  again,  does  not  fail  to  rupture 
them.  , 

Where  the  membranes  have  given  way  spontaneously  very  high 
up  above  the  cervix,  and  the  tumour  that  had  engaged  in  the  vagina 
does  not  disappear,  and  seems  to  interfere  with  the  progress  of  the 
natural  phenomena  of  the  labour,  we  ought  most  generally  to  per- 
forate them  as  if  nature  hJd  not  yet  effected  it.  Lastly,  when  the 
membranous  sac  does  not  permit  the  liquor  amnii  to  escape  until 
long  after  the  dilatation  of  the  orifice,  as  it  is  generally  found  that 
the  rest  of  the  labour  proceeds  with  great  celerity,  the  woman 
should  always  from  the  time  the  rupture  takes  place  preserve  a 
horizontal  posture. 

853.  Another  cause  of  protracted  labour  is  the  weakness,  whether 
absolute  or  relative,  of  the  uterine  contractions  ;  this  is  almost  always 
the  cause  that  is  kept  in  view  by  the  authors  of  oxytocic  remedies  ; 
nevertheless  it  is  fa^r  from  being  the  most  common  one,  and  as  the 
means  proper  to  overcome  it  are  most  generally  hurtful  in  the  other 
cases,  it  is  easy  to  explain  the  discordance  met  with  in  the  works  on 
the  effects  of  substances  employed  to  accelerate  the  process  of  par- 
turition. 

When  the  inaction  of  the  womb  is  evident,  and  depends  neither 
upon  general  nor  local  fatigue,  when  it  prevents  the  labour  from 
proceeding,  and  the  attention  and  regimen  which  were  spoken  of 
at  the  commencement  of  this  article  have  been  tried  in  vain,  and 
especially  when,  instead  of  diminishing,  it  goes  on  increasing  hour 
after  hour,  those  substances  that  seem  to  exert  a  special  action  on 
the  gestative  organ  should  be  tried.  This  is  the  case  in  which 
small  injections  of  senna  are  indicated  ;  in  which  stimulants  in 
general  are  indicated  ;  in  which  the  borate  of  soda,  extolled  by  the 
ancients,  by  Romberg  among  others,  and  in  our  own  day  by  M. 
Lobstein,  might  be  successfully  administered  ;  but  a  substance  is 
now  known  that  seems  to  deserve  a  preference  over  all  others,  and 
of  which  I  am  about  to  speak  in  more  detail.  ;  • 

854.  The  ergoted  rye,  clavus  secalinus^  secale  luxurians^  calcar^ 
secale  mater,  (ble  farouche,  blc  noir,  ble  cornu,  ble  ivre,  ergot,  seigle 
eperone,  clou  de  seigle,  seigle  de  matrice)  seems  to  have  been  used 
from  time  immemorial  by  the  old  women,  and  by  some  country  mid- 
wives  for  the  purpose  of  hastening  delivery;  it  was  mentioned  in  the 
Acta  Natur.  Curios,  for  1688,  and  the  title  of  womb-rye  which  was 
adopted  by  the  Germans  shows  that  this  idea  was  not  a  new  one. 
These  traditions  of  the  vulgar  at  length  attracted  the  attention  of 
the  profession,  and  M.  Desgranges  published  his  first  researches  upon 

2  V 


I 


362  EUTOCIA. 

the  oxytocic  properties  of  the  ergoted  rye  in  the  Gazette  de  Sante 
for  1777.  Since  that  period  numerous  observations  have  been  col- 
lected and  made  public  in  the  American,  English,  and  French  jour- 
nals, &c.  &c.  Stearns,  Prescot,  Chapman,  Bordot,  Goupil,  Chev- 
reul,  Legras,  Bigeschi,  Gendrin,  and  especially  M.  Villeneuve,  have 
collected  an  infinite  number  of  facts  that  prove  decisively  that  the 
ergot  of  rye  is  capable  of  restoring  the  contractions  of  the  womb 
during  labour.  However,  MM.  Desorrheaux  and  Capuron  do  not 
appear  to  have  much  confidence  in  it,  and  Madame  Lachapelle  has 
published  a  long  series  of  experiments,  which  tend  to  show  that  it 
enjoys  no  property  of  the  kind,  whether  given  in  fine  or  coarse  pow- 
der, in  infusion  or  in  decoction,  in  extract  or  in  syrup.  In  the  last 
four  years  I  have  used  it  more  than  twenty  times;  M.  Delanglar  and 
M.  Terreux  have  also  used  it  at  my  solicitation,  and  in  every  case 
its  action  has  appeared  to  be  evident,  undeniable.  It  forces  the 
uterus  to  contract  in  a  few  minutes,  in  a  quarter  of  an  hour,  or,  at 
most,  in  twenty  minutes  after  it  is  exhibited.  I  have  very  recently  had 
another  most  convincing  proof  of  its  efficacy:  to  a  young  woman 
who  had  been  twenty-four  hours  in  labour,  I  gave  three  doses  in  the 
space  of  forty  minutes;  within  five  minutes  after  the  first  one,  the 
pains,  which  had  for  several  hours  been  very  feeble  and  slow,  sud- 
denly became  strong  and  very  frequent,  but  soon  relaxed  again;  the 
second  dose  brought  them  back  in  the  same  way:  they  diminished  a 
second  time,  and  it  was  not  until  after  the  third  dose  that  they  were 
maintained  until  the  complete  expulsion  of  the  fcetus,  which  soon 
took  place. 

I  prescribe  it  in  the  quantity  of  fifteen  or  twenty  grains  in  a 
spoonful  or  half  a  wine  glassful  of  sweetened  water,  and  repeat  the 
dose  two  or  three  times,  at  intervals  of  fifteen  or  twenty  minutes. 
Perhaps  a  larger  quantity  may  be  safely  given:  Parmentier  took  half 
a  drachm  of  it;  MM.  Lapre  and  Campernon  a  drachm,  and  a 
drachm  and  a  half,  for  several  days  together,  without  experiencing 
any  sensible  eflects  from  it;  its  use  might  therefore  be  continued  for 
a  long  time  and  in  large  doses,  before  any  well  grounded  fear  of 
inducing  ergotism  could  be  entertained. 

855.  It  is  to  be  hoped  that  the  chemists  will  ere  long  separate  the 
essentially  active  principle  of  this  substance;  MM.  Desgranges  and 
Lapre  have  already  observed  that  four  or  five  grains  of  the  bark 
produce  a  greater  effect  than  twelve  or  fifteen  of  the  entire  grain. 
I  have  no  doubt  that  a  preparation  will  be  discovered  ere  long, 
whoso  energy  shall  ho  uniform;  but,  meanwhile,  a  fine  powder  made 
of  the  entire  grain  appears  to  me  to  be  preferable  to  the  decoctions, 
extracts,  &c.  >jty^'"'" ' 


MANAGEMENT  OF  LABOUR.  363 

"  866.  In  order  that  the  ergot  of  rye  may  be  given  with  some  chance 
of  success,  and  without  any  danger,  it  is  necessary,  1st,  that  there 
should  be  no  manifest  tendency  to  hemorrhage  from  excess  of  irrita- 
tion; 2d,  that  it  be  possible  for  the  delivery  to  take  place  through  the 
natural  passages;  3d,  that  the  child  be  in  a  good  position;  4tb,  that 
the  cervix  be  soft  and  dilatable;  6th,  that  the  general  irritability  be 
not  too  great;  6th,  that  the  digestive  organs  be  in  a  good  state,  and 
7th,  that  the  weakness  of  the  uterine  action  shall  depend  upon  the 
want  of  irritability  of  that  organ.  M.  Legras  advises  that  it  be 
given,  also,  for  the  purpose  of  steadying  the  head  at  the  superior 
strait,  previously  to  applying  the  forceps. 


ARTICLE  III. 

Of  Dystocia,  or  Difficult  Labour  {preternatural  labour,  la- 
borious I.,  mechanical  I.,  manual  I.,  artificial  I.,  <^c.). 

867.  Labour  ceases  to  deserve  the  title  of  spontaneous,  whenever, 
by  leaving  it  wholly  to  the  powers  of  nature,  it  threatens  to  become 
dangerous  either  to  the  mother  or  child.  These  kinds  of  labour 
were  for  a  long  time  designated  by  the  simple  epithets  of  preterna- 
tural or  laborious:  but  the  distinct  acceptation  that  was  attempted 
to  be  given  to  each  of  these  qualifications  being  quite  arbitrary,  too 
much  confusion  has  ensued  among  the  authors  who  adopted  them, 
not  to  make  it  desirable  to  replace  them  by  others.  As  the  name 
of  dystocia*,  employed  by  Hippocrates,  Sauvages,  and  M.  Desor- 
meaux,  expresses  aH  the  cases  that  require  the  assistance  of  art,  it 
appears  to  me  the  most  proper  one,  and  will  doubtless  be  preferred 
at  a  future  day  as  a  generic  term. 

858.  As  to  the  subdivisions  to  be  established,  it  is  contrary  to  the 
rules  of  reasoning  to  found  them  upon  the  nature  of  the  means  that 
are  employed  where  nature  is  insufficient  for  us  any  longer  to  con- 
form to  the  principles  laid  down  by  Solayres,  Baudelocque,  &c.  The 
faults  of  such  a  method  are  too  evident  for  it  to  be  necessary  to 
enumerate  them;  it  should  suffice  us  to  remember  that  by  following 
them,  the  same  cause  of  dystocia,  the  same  accident,  for  example 
a  hemorrhage,  may  by  turns  cause  the  same  fact  to  be  classed  by 
turns  among  the  preternatural,  laborious,  mechanical,  mixed,  manual, 

•  From  (Twf,  an  inseparable  particle  which  imports  difficulty,  trouble,  misfor- 
tune, and  rcxot,  child-birth- 


364  DYSTOCM. 

&c.  labours,  according  to  the  ability  or  good   pleasure  of  the 
accoucheur. 

It  is,  therefore,  infinitely  better  to  base  them  upon  the  causes  that 
may  give  rise  to  difficult  labour.  This  plan,  which  has  been  adopted 
by  Merriman  and  M.  Desormeaux,  exhibits  real  and  indisputable 
advantages  ;  it  readily  applies  to  all  possible  cases,  enables  us  to 
reduce  or  multiply  genera  and  species  without,  in  any  way,  interfering 
with  the  general  classification,  and,  besides,  can  combine  with  all 
the  other  methods  proposed  by  the  various  authors.  After  all,  diffi- 
cult labour  is  characterised  by  the  accident  which  complicates  it,  and 
not  by  the  kind  of  assistance  required  in  it. 

859.  The  causes  that  render  labour  difficult  depend  either  upon 
the  mother  or  the  child.  Some  of  them  are  unforeseen,  do  not  occur 
until  the  moment  of  parturition  ;  the  title  of  accidental  may  be 
appropriated  to  them.  Others  exist  beforehand,  and  render  the 
labour  necessarily  difficult :  they  merit  the  denomination  of  pre-ex- 
isting causes. 

The  accidental  or  unforeseen  causes  ate :  any  serious  disease,  such 
as  inflammation  of  the  brain  or  its  coverings,  of  the  lungs  or  pleura, 
of  the  peritoneum  or  uterus,  &c.  which  takes  place  during  labour ; 
any  hemorrhage  sufficiently  abundant  to  endanger  the  life  of  the 
mother  or  her  offspring ;  convulsions,  syncope,  laceration  of  the 
womb,  the  premature  escape  bf  the  cord,  hernia,  aneurism,  asthma, 
great  debility,  &c.,  and  some  positions  which  do  not  become  bad 
until  after  the  first  pains. 

The  pre-existing  causes  are :  deformities  of  the  pelvis,  malfor- 
mation or  disease  of  the  organs  of  generation,  calculus  in  the  blad- 
der, fibrous  or  other  tumours  in  the  excavation,  deformities  in  respect 
to  height,  transverse  positions,  monstrous  conformation,  and  diseases 
of  the  foetus. 

As  these  different  causes  are  in  reality  only  complications  of 
labour,  it  follows  that  dystocia  comprises  all  cases  of  complicated 
labour,  as  eutocia  comprehends  all  simple  labours. 

SECTION  1. 
Accidental  Dystocia. 

§  1 .  Of  hemorrhagic  dystocia. 

Whether  the  hemorrhage  be  an  epistaxis,  an  hemoptysis,  an  he- 
rnatemesis,  a  hematuria,  or  a  metrorrhagia,  any  one  may  conceive 
that  the  efl^orts  of  child-birth  must  to  a  considerable  degree  augment 
the  danger  which  accompanies  it.      In  the  five  first  named  cases  we 


HEMORRHAGIC  DYSTOCIA.  365 

are  to  act  as  we  should  do  in  relation  to  all  hemorrhages  in  general; 
and  if  the  blood  still  continues  to  flow,  we  should  begin  to  think  of 
terminating  the  labour  as  promptly  as  possible  ;  the  sixth-named 
case,  uterine  hemorrhage,  is  met  with  so  frequently,  constitutes  an 
accident  of  so  serious  a  nature,  that  it  becomes  necessary,  in  this 
place,  to  examine  it,  not  only  as  a  complication  of  labour,  but  also 
as  one  of  the  essential  and  distinct  diseases  of  pregnant  women. 

860.  This  hemorrhagy  is  called  internal,  latent,  or  conceaeld  he- 
morrhage, when  the  blood  that  flows  from  the  vessels  is  retained  in 
the  womb  and  does  not  escape  from  the  genital  organs  ;/it  is,  on  the 
contrary,  denominated  external,  apparent,  when  the  sanguineous 
fluid  escapes  from  fhe  genital  organs  as  fast  as  it  is  poured  out  by 
the  mouths  of  the  vessels.  It  is  owing  to  two  kinds  of  causes  :  effi' 
dent  causes,  and  occasional  or  determining  causes. 

861.  From  the  time  of  Puzos,  accoucheurs  have  generally  placed 
the  eflficient  cause  of  flooding  in  the  detachment  of  the  placenta ; 
they  state  that  the  placenta  separates  itself  from  the  internal  surface 
of  the  womb,  and  thenceforth  the  blood  flows  abundantly  from  the 
large  and  numerous  vessels  which  open  on  it;  this  opinion  appears 
to  me  to  be  ill-founded.  Puzos  and  his  partizans  have  mistaken  the 
effect  for  the  cause.  It  is  not  the  detachment  of  the  placenta  that 
produces  the  hemorrhage,  but  the  hemorrhage  on  the  contrary  that 
detaches  the  placenta :  blows,  falls  and  great  shocks  may  certainly 
afl^ect  the  womb  and  its  contents ;  but  as  the  ovum  constitutes  a  full 
bladder  in  immediate  contact  with  the  whole  extent  of  the  cavity  of 
the  organ  that  contains  it,  the  most  violent  commotions  would  not 
be  able  to  detach  it.  While  ever  the  membranes  remain  unrup- 
tured, it  cannot  be  conceived  how  the  adherences  of  the  placenta 
can  be  destroyed  otiierwise  than  by  the  efforts  of  a  fluid  endeavour- 
ing to  eflfuse  itself  into  the  cavity  of  the  womb.  It  is  astonishing 
that  such  a  doctrine  should  have  been  maintained  so  long  by  so 
many  celebrated  men ;  for  even  admitting  a  previous  detachment  of 
the  placenta,  we  should  still  have  given  no  explanation  of  floodings. 
In  fact  this  detachment  takes  place  every  day,  either  wholly  or  par- 
tially, from  the  middle  stage  of  the  most  natural  labour,  and  not- 
withstanding there  is  no  hemorrhage.  Besides,  an  anatomical  dis- 
position that  has  no  real  existence  is  relied  on  here,  the  ovum  is 
merely  stuck  (plaque)  on  the  inner  face  of  the  womb,  and  not  in- 
timately united  to  it ;  the  placenta  and  organ  of  gestation  commu- 
nicate with  each  other  only  by  means  of  pores,  and  not  by  means 
of  large  vascular  mouths. 

862.  The  efficient  cause  of  flooding  seems  to  me  to  be  analogous 
to  those  of  all  other  hemorrhagies,  to  that  of  epistaxis,  for  instance. 


366  DYSTOCIA. 

The  sanguine  exhalation  takes  place  in  the  womb  as  it  does  in  the 
nose,  under  the  influence  of  a  local  congestion,  an  affluxion,  a  pe- 
culiar state  of  irritation,  of  the  molimen  hemorrhagicum  so  much 
talked  of  by  Stahl.  When  this  affluxion,  or  molimen^  exists  to  a 
certain  degree,  the  blood  transudes  with  greater  or  less  force,  and 
from  a  more  or  less  extensive  surface,  as  happens  during  the  pre- 
sence of  the  menses  ;  only,  it  requires  a  stronger  impulsion,  because, 
during  pregnancy,  the  ovum  that  it  is  compelled  to  detach  in  order 
to  effect  a  passage,  necessarily  presents  a  certain  degree  of  resistance 
to  it ;  moreover,  it  seems  to  me,  that  in  respect  to  its  intimate  me- 
chanism, an  uterine  hemorrhage  that  does  not  depend  upon  any 
traumatic  lesion,  is  always  the  same,  at  whatever  period  and  in  what- 
ever condition  it  may  occur,  as  well  during  gestation  as  during  and 
after  parturition. 

The  idea  which  I  now  set  forth,  and  which  is  nearly  similar  to 
that  which  has  already  been  taught  by  Costa,  M.  Desormeaux, 
Madame  Lachapelle  and  M.  Duges,  merits  the  most  serious  atten- 
tion, and  ought  to  have  great  influence  on  the  therapeutics  of  flood- 
ing, and  upon  some  other  points  of  tokological  science. 

The  determining  causes  are  as  numerous  as  they  are  diversified  ; 
Ihey  may  be  referred  to  a  general  state  of  the  woman,  to  a  peculiar 
state  of  the  sexual  organs,  and  to  external  accidents. 

863.  General  state.  StoU,  Finke  and  other  observers  have  re- 
marked that  during  the  prevalence  of  certain  epidemics,  all  the 
bilious  affections  were  accompanied  with  metrorrhagy  :  it  has  been 
stated  that  verminose  diseases,  various  lesions  of  the  alimentary 
canal,  and  all  those  indispositions  that  are  accompanied  with  sympa- 
thetic reaction  upon  the  womb,  are  capable  of  giving  rise  to  it. 
Fatigue,  frequent  attendance  at  balls,  plays,  whole  nights  passed 
without  sleep,  an  exciting  regimen,  heating  liquors,  purgatives,  the 
warm  bath,  substances  used  to  produce  abortion,  moral  commotions, 
in  fine,  whatever  tends  to  render  the  menstrual  flux  more  abundant 
and  more  precocious,  is  also  capable  of  giving  rise  to  the  flooding ; 
to  these  causes  may  be  added  an  ulcer,  a  polypus  at  the  neck  of  the 
womb,  fibrous  and  other  tumours  in  the  substance  of  the  parietes, 
or  in  the  neighbourhood  of  the  external  surface  of  the  uterus,  cri- 
minal maneuvres,  and  every  thing  calculated  to  produce  a  determi- 
nation of  fluids  towards  the  pelvis,  violent  exertions,  the  jolting  of  a 
rough-^oing  carriage,  riding  on  horseback,  efforts  to  carry  or  lift  a 
heavy  burthen,  coughing,  vomiting,  shocks  communicated  to  the 
trunk  of  the  body  by  falls  upon  the  feet  the  knees  or  seat,  blows 
on  the  abdomen  or  pelvis,  diseases  of  the  rectum  and  bladder ;  in 
one  word,  all  conditions,  whether  of  temperament  or  of  disease,  all 


HEMORRHAGIC  DYSTOCIA.  367 

circumstances,  whether. natural  or  eventual,  that  are  susceptible  of 
producing  a  sanguine  congestion,  a  raptus  towards  the  vessels  of 
the  womb,  and  all  the  causes  of  abortion  ;  so  that  pregnancy  and 
labour  in  themselves  constitute  one  of  its  most  powerful  causes. 

864.  In  some  particular  cases,  an  entirely  special  cause  of  hem- 
orrhage is  superadded  to  the  preceding  ones,  and  may  of  itself  pro- 
duce the  flooding  ;  I  mean  the  implantation  of  the  placenta  over 
the  cervix  uteri. 

Whether  the  placenta  corresponds  to  the  orifice  by  its  very  cen- 
tre or  by  some  point  more  or  less  near  its  circumference,  there  re- 
sults nevertheless  a  hemorrhage  whose  distinctive  character  is,  that 
it  occurs  only  in  the  last  months  of  gestation,  or  from  the  period 
when  the  cervix  uteri  begins  to  dilate  from  above  downwards.  Th^e 
authors  who  attribute  it  to  the  rupture  of  the  utero-placental  vessels 
have  certainly  been  deceived  by  theoretical  prejudices,  or  false  ana- 
tomical appearances.  I  offer  the  following  as  the  results  of  several 
observations  collected  with  great  care. 

When  the  placenta  is  inserted  upon  the  neck  of  the  womb,  these  two 
parts  proceed  together  in  their  development  until  about  the  fifth,  the 
sixth,  the  seventh,  and  sometimes  even  until  eight  months  and  a  half; 
•but  from  that  time  forwards,  the  environs  of,the  orifice  are  so  rapidly 
withdrawn  from  the  centre,  that  a  constantly  increasing  portion  of 
the  ovum  necessarily  remains  without  any  adherence  to  the  womb, 
and  this  portion,  which  is  soft,  vascular,  and  constantly  on  the 
stretch,  may  crack  or  even  tear,  and  thus  give  rise  to  a  hemorrhage 
which  puts  the  child's  life  much  more  at  hazard  than  the  mother's. 
On  the  other  hand,  this  displacement  does  not  in  general  take  place 
without  the  inferior  portion  of  the  womb  being  more  or  less  irritated 
by  it,  and  soon  becoming  the  seat  of  an  affluxion,  a  more  or  less 
decided  congestion,  and  thenceforth,  the  general  eficient  cause  of 
floodings  is  superadded  to  the  peculiar  cause  constituted  by  the 
presence  of  the  placenta  on  the  cervix.  Is  it  necessary  for  me  to 
remark  that  these  two  causes,  the  rupture  of  some  vessels  of  the 
placental  parenchyma,  and  a  state  of  congestion  of  the  uterus,  may 
exist  separately  ;  that  although  the  former  almost  always  super-in- 
duces the  latter,  it  is  not,  however,  impossible  for  it  to  exist  alone, 
and  that  the  latter  may  pre-exist,  or  even  exist  to  such  an  extent  as 
to  give  rise  to  the  most  imminent  danger,  without  necessarily  com- 
bining with  the  other  ?  Besides,  it  is  well  known,  that  blows, 
shocks,  vivid  emotions,  and  all  the  other  causes  of  ordinary  uterine 
hemorrhage  are  equally  fitted  to  produce  it  where  the  placenta  is 
inserted  over  the  orifice  ;  it  therefore  follows  that  both  these  kind* 
of  flooding  depend  on  the  same  proximate  cause,  the  hemorrhagic 


368  DYSTOCIA. 

moUmen,  and  upon  the  same  occasional  causes  ;  but  that  the  presence 
of  the  placenta  upon  the  cervix  constitutes  a  peculiar  determining 
cause,  which  rarely  fails  of  being  in  itself  sufficiently  powerful  to 
produce  it. 

866.  Vessels  of  the  cord.  It  is  at  present  pretty  generally  be- 
lieved that  the  vessels  of  the  umbilical  cord  may  break  during  labour, 
and  give  rise  to  one  of  the  most  serious  kinds  of  hemorrhage. 
Doubtless,  it  would  not  be  wise  to  deny  the  possibility  of  such  an 
accident ;  but  it  must  be  confessed  that  the  observations  relied  upon 
to  prove  it  are  any  thing  but  conclusive.  The  one  mentioned  by 
Lamotte  was  evidently  only  a  case  of  ordinary  hemorrhage  :  the 
blood  had  begun  to  flow  previously  to  the  rupture  of  the  mem- 
KVanes  ;  the  woman  rapidly  grew  weak,  and  the  author  believed  that 
the  hemorrhage  took  place  from  the  cord,  because  he  found  one  of 
its  vessels  to  appear  as  if  eroded  to  such  a  degree  as  to  admit  of  the 
transudation  of  blood.  Levret's  case,  when  carefully  analysed, 
proves  nothing  more  in  favour  of  the  opinion  of  the  surgeon  of 
Valogne  ;  and  the  case  by  Baudelocque,  who  at  first  refused  to  coin- 
cide with  the  opinion  of  Levret,  certainly  ought  not  to  have  induced 
him  to  change  his  views.  Had  the  rupture  of  the  cord  been  the 
xause  of  the  hemorrhage,  the  fcetus  would  not  have  been  born  alive 
in  the  cases  reported  by  De  la  Motte  and  Baudelocque.  In  the 
example  cited  by  Levret,  the  foetus,  it  is  true,  was  dead  born,  but 
the  forceps  had  been  employed,  and  the  meconium  continued  to 
come  away  while  blood  was  still  flowing.  In  fine,  in  allthree  cases, 
the  mothers  became  so  weak  as  to  excite  the  serious  alarm  of  the 
accoucheur ;  which  seems  to  me  clearly  to  demonstrate  that  tlie 
blood  came  from  the  uterus  and  not  from  the  child.  Did  the  nature 
of  this  work  admit  of  it,  it  would  be  an  easy  matter  for  me  to  show 
that  none  of  the  reasons  invoked  by  these  authors  are  capable  of 
demonstrating  the  correctness  of  the  opinion  they  desire  to  support : 
let  it  suffice  me  to  say  that  in  the  actual  state  of  our  knowledge,  the 
hemorrhage  from  the  cord,  as  understood  by  De  la  Motte,  Levret, 
and  Baudelocque,  can  only  be  admitted  as  possible,  and  not  as 
proved.  In  this  respect,  moreover,  I  am  completely  of  accord  with 
Mesdames  Boivin  and  Lachapelle. 

866.  Nevertheless,  the  umbilical  vessels,  and  their  branches  rami- 
fying upon  the  fetal  surface  of  the  placenta,  arc  sometimes  subjected 
to  rupture  ;  I  am  in  possession  of  several  examples  of  the  kind  ;  but 
it  is  because  they  were  previously  in  a  diseased  state,  and  that  too 
generally  in  the  early  periods  of  pregnancy.  Then,  the  fcetus  dies 
.promptly,  abortion  takes  place,  and  the  hemorrhage  is  not  discovered 
until  the  ovum  comes  to  be. examined.     I  have  very  often  found 


FLOODING.  369 

embryos  of  six  weeks,  two  months,  &c.  still  enveloped  in  the  mem- 
branes, separated  wliolly  or  partially  from  their  cord,  close  to  which 
were  discovered  one  or  more  small  clots  of  blood ;  at  other  times 
small  varicose  or  aneurismal  sacs,  sometimes  upon  the  cord,  some- 
times upon  the  secondary  divisions  of  its  vessels,  the  walls  of  which 
are  exceedingly  thin,  and  liable  to  be  ruptured  by  the  slightest  effort. 
In  an  after-birth  at  full  term,  I  have  seen  some  of  these  dilatations 
that  had  been  ruptured,  and  which  communicated  with  a  large  clot 
covering  a  part  of  the  placenta,  and  which  had  not  lacerated  the 
amnios  ;  but  it  is  easy  to  perceive  that  this  kind  of  accident  is  but 
indirectly  similar  to  those  spoken  of  by  authors. 

867.  Diagnosis.  Uterine  hemorrhages  have  certain  common 
symptoms  and  certain  peculiar  signs  ;  among  the  general  signs, 
there  are  some  which  announce  the  approach  of  hemorrhage,  and 
others  which  accompany  or  succeed  it. 

868.  Precursory  signs.  Although  in  some  women  the  flooding 
appears  on  a  sudden,  and  without  any  precursory  symptoms,  it  is 
not  the  less  true  that  this  accident  is  almost  always  preceded  by 
a  more  or  less  decided  disorder  of  seme  function.  Thus,  one 
or  more  hours,  or  one  or  even  several  days  before  the  appear- 
ance of  the  blood,  the  individual  has  a  sense  of  uneasiness,  rest- 
lessness in  the  limbs,  weight,  fullness  in  the  pelvis,  alternate  flushes 
and  chills  throughout  the  body,  and  rather  more  thirst  and  less  ap- 
petite than  common  ;  flushes  of  heat  ascend  to  her  head  ;  she  has 
fits  of  giddiness,  and  becomes,  much  redder  or  paler  than  in  her 
habitual  state  ;  the  pulse  acquires  strength,  frequency,  and  quick- 
ness ;  there  is,  pretty  commonly,  a  degree  of  febrile  action. 

869.  Signs  of  flooding.  When  a  quantity  of  blood  sufficient  to 
excite  alarm  has  flowed,  the  pulse  loses  somewhat  of  its  strength  and 
hardness,  soon  becomes  irregular  and  tremulous ;  the  face  grows  pale 
and  the  skin  cooler ;  dimness  of  sight,  ringing  in  the  ears,  and  weaJe- 
ness  of  the  stomach,  which  induce  the  woman  to  ask  for  some  kind 
of  aliment ;  yawning,  pandiculation,  nausea,  lipothymia,  syncope  and 
even  convulsive  movements  appear  in  succession,  and  sometimes 
with  frightful  rapidity. 

In  external  floodings,  the  precursory  symptoms  are  succeeded  by 
a  discharge  of  blood  from  the  external  organs,  and  this  character- 
istic is  too  evident  for  it  to  be  needful  to  indicate  any  others ; 
nevertheless,  it  has  appeared  to  be  difficult  to  some  persons,  not  to 
confound,  at  times,  a  real  flooding  with  a  simple  menorrhagia. 
Baudelocquc  did  all  in  his  power  to  clear  up  this  point  of  diagnosis  : 
according  to  him,  menstruation  occurring  during  pregnancy  diflfers 
from  metrorrhagia,  properly  so  called,  in  respect  that  it  takes  place 
2  W 


370  DYSTOCIA. 

without  any  pain,  without  effort,  without  any  notable  disorder  of  the 
health,  without  any  antecedent  molimen ;  in  respect  that  the  fluid 
which  escapes  is  serous,  very  slightly  coloured,  and  does  not  coagu- 
late ;  in  that  it  is  very  small  in  quantity,  terminates  in  two,  three,  or 
four  days,  appears  at  the  ordinary  epochs  of  the  menstrual  flux,  and 
that  far  from  debilitating,  it  is,  on  the  contrary,  followed  by  an  im- 
preved  state  of  health,  and  greater  freedom  in  the  exercise  of  the 
functions  ;  while  the  very  opposite  circumstances  are  observed  in  a 
real  hemorrhagy.  But,  in  looking  a  little  closer  at  the  subject,  it  is 
soon  found  that  these  characteristics  are  for  the  most  part  quite 
illusory.  In  the  first  place,  it  is  a  fact  that,  in  many  women  the 
menses  are  frequently  preceded  by  the  same  symptoms  as  the  most 
dangerous  floodings,  and  that  the  blood  of  the  menses,  far  from 
being  fluid  and  colourless  in  all  cases,  is  on  the  contrary  sometimes 
charged  with  cruor  and  very  coagulable  ;  besides,  flooding  is  not 
always  accompanied  or  announced  by  the  general  signs  heretofore 
indicated  ;  it  may  be  very  moderate  in  the  beginning,  and  formed 
of  serous  blood,  or  blood  charged  with  fibrine,  and  coincide  with 
one  of  the  catamenial  epochs  ;  indeed,  as  the  mechanism  of  men- 
struation is  the  same  with  that  of  metrorrhagia,  I  do  not  see  that  it 
is  possible  to  distinguish  the  one  from  the  other  by  any  special 
signs.  Moreover,  this  differential  diagnosis  leads  to  nothing  ;  while 
the  flow  is  slight,  the  precautions  prescribed  by  art  are  incapable 
of  interfering  injuriously  with  the  menstrual  function  ;  and  as  soon 
as  the  blood  escapes  in  sufficient  quantity  to  require  more  active 
interference,  it  would  be  almost  ridiculous  any  further  to  seek  to 
discriminate  between  menorrhagia  and  metrorrhagia. 

870.  In  internal  flooding^  admitted  by  Mauriceau,  De  la  Motto, 
Levret,  Baudelocquc  and  Merriman,  who  have  related  cases  of  it,  the 
blood  tends  to  accumulate  between  the  placenta,  or  membranes,  and 
the  corresponding  part  of  the  womb ;  a  lenticular  coagulum  might  in 
such  case  form  with  variable  rapidity,  depressing  the  ovum  in  an  ec- 
centric manner  on  the  one  hand,  and  on  the  other  compelling  the  ute- 
rus to  distend  mechanically,  so  as  to  receive  the  fluid  that  is  effused  :  I 
am  aware,  that  in  presence  of  facts,  argument  ought  to  be  silent ;  but 
then,  those  facts  ought  to  be  incontestable,  well  noted,  and  properly 
interpreted  :  now  can  these  conditions  be  recognised  in  a  majority 
of  those  that  have  been  mentioned  in  favour  of  internal  floodings? 
Is  it  quite  certain  that  the  blood  in  some  instances  found  betwixt 
the  placenta  and  the  womb  had  accumulated  there  during  life,  rather 
than  immediately  after  death  ;  that  that  which  escaped  in  torrents  as 
the  membranes  gave  way  was  not  eflfused  before  hand  in  the  interior 
of  the  amnios  ?   How,  indeed,  can  we  conceive  that  the  blood  which 


FLOODING.  .  371 

escapes  from  the  uterine  vessels  in  somewhat  considerable  quantities 
is  capable  of  dilating  beyond  measure,  and  almost  instantaneously,  the 
cavity  of  the  womb,  instead  of  running  between  the  gestative  organ 
and  its  contents,' so  as  to  escape  outwards,  or  of  rupturing  the  mem- 
branes and  becoming  effused  within  their  cavity?  How  can  we 
admit  that  the  adherences  of  the  placenta,  which  are  habitually  so  , 
weak,  could  resist  the  effort  of  the  blood,  tending  to  form  a  new 
cavity  for  its  own  reception,  more  powerfully  than  the  uterus,  which 
yields  with  so  much  difficulty  ? 

Until  these  various  questions  shall  be  solved  rigorously,  I  shall 
continue,  with  Mesdames  Boivin  and  Lachapelle,  to  think  that  the 
existence  of  internal  flooding,  such  as  it  is  generally  understood, 
ought  not  to  be  admitted,  except  under  pretty  numerous  restrictions, 
and  also,  that  what  has  been  hitherto  said  in  relation  to  it  needs  con- 
firmation. 

It  should  in  all  cases  be  accompanied  with  the  same  symptoms  as 
external  hemorrhagy,  from  which  it  should  be  distinguishable  only  by 
the  absence  of  blood  flowing  externally,  or  by  the  unnatural  size  of 
the  womb  or  abdomen. 

871.  Flooding  with  implantation  of  the  placenta  over  the  cervix. 
According  to  Rigby,  floodings  produced  by  the  attachment  of  the 
placenta  in  the  vicinity  of  the  orifice,  ought  to  be  of  extremely  fre- 
quent occurrence  ;  for,  in  one  hundred  and  six  cases,  he  met  with 
it  forty-three  times,  and  Madame  Lachapelle  goes  so  far  as  to  say 
that  uterine  hemorrhage  occurring  in  the  three  last  months  of  preg- 
nancy, depends  almost  upon  no  other  cause.  Be  this  as  it  may,  this 
kind  of  flooding  is  distinct  from  other  species,  in  that,  it  never  takes 
place  before  the  fifth  month  ;  that  the  blood,  at  first,  flows  in  small 
quantity,  and  stops  of  its  own  accord,  to  re-appear  in  greater 
abundance  after  a  week  or  two  ;  in  that,  it  pretty  often  comes  on 
without  any  assignable  cause,  or  precursory  symptoms ;  that  it 
returns  after  shorter  intervals,  and  is  in  greater  abundance  as  the 
stage  of  pregnancy  is  more  advanced  ;  in  that,  during  labour,  the 
blood  flows  especially  during  the  contractions,  and  not  in  the  inter- 
vals, as  in  the  other  species.  When  it  commences  early,  as  the 
blood  flows  in  small  quantity,  the  woman  becomes  exhausted  but 
slowly,  the  muscles  become  osdematous,  the  face  is  bloated,  the  lips 
grow  pale,  and  the  skin  soon  assumes  a  dull  yellow  tint,  the  colour  of 
wax,  through  its  whole  extent.  These,  however,  are  only  rational 
signs,  which  may  even  not  be  met  with  near  the  commencement  of 
the  flooding  ;  whenever,  therefore,  it  becomes  desirable  to  remove 
all  doubt  upon  the  subject,  recourse  should  be  had  to  the  touch.  The 
orifice  is,  in  general,  very  sof\,  and  somewhat  dilated  ;  instead  of  the 


372  .  DYSTOCIA. 

membranes,  a  spongy  body  is  felt,  engaged,  as  the  point  of  a  cone 
with  a  large  base  might  be,  in  the  upper  part  of  the  cervix ;  but  care 
should  be  taken  not  to  mistake  a  coagulum  of  blood  for  the  placenta, 
and  in  order  that  the  operation  should  not  be  performed  unnecessa- 
rily, to  recollect  that  this  exploration  may  possibly  reproduce  the 
hemorrhage,  by  disturbing  the  concretions  by  means  of  which  the 
economy  had  succeeded  in  suspending  it. 

872.  Instead  of  following  the  course  that  T  have  just  indicated  as 
the  most  general  one,  the  hemorrhage  sometimes  pursues  a  very 
different  one.  M.  Duparcque  lias  seen  a  case  which  came  on  as  early 
as  the  sixth  month,  which  ceased  spontaneously,  and  did  not  return 
until  the  appearance  of  the  labour.  M.  Desormeaux  has  met  with  it 
once  in  the  fifth  month;  and  it  became  so  profuse  in  the  sixth,  that  it 
was  found  necessary  to  deliver  the  woman.  I  have  seen  a  case  where 
it  did  not  appear  until  the  end  of  the  ninth  month,  in  a  woman  to 
whom  I  was  called  by  M.  Baroilhet,  and  where  it  did  not  become 
serious  until  the  approach  of  her  confinement,  although  the  centre 
of  the  placenta  was  situated  over  the  orifice.  In  other  cases,  espe- 
cially in  first  pregnancies,  and  where  the  uterus  is  very  much 
inclined  in  front,  the  os  uteri  is  sometimes  so  little  opened,  and  so 
high  up,  that  the  blood  may  accumulate  below  it,  to  a  certain 
amount,  and  in  some  sort  produce  an  internal  hemorrhagy.  Did  the 
flooding  depend  upon  the  rupture  of  some  of  the  vessels  of  the  pla- 
centa or  cord,  it  would  be  characterised  by  causing  the  sudden 
death  of  the  fa3tus,  and  by  debilitating  the  mother  secondarily. 
Moreover,  it  would  doubtless  produce,  as  in  cases  where  the  blood 
is  effused  into  the  interior  of  the  membranes,  a  feeling  of  weight  in 
the  pelvis  and  hypogastrium,  with  dragging  in  the  loins,  the  groins, 
and  about  the  pit  of  the  stomach. 

873.  Prognosis.  The  dangers  that  follow  in  the  train  of  uterine  he- 
morrhage necessarily  vary  according  to  a  multitude  of  circumstances, 
according  to  the  species  and  amount  of  the  flow,  the  stage  of  the 
pregnancy,  and  the  ability  of  the  prescribing  attendant.  In  the 
early  stages  of  pregnancy  it  is  rare  for  the  woman  not  to  be  saved, 
for  abortion  is  nearly  an  invariable  consequence  of  it.  In  the  last 
three  months,  on  the  contrary,  the  life  of  the  child  is  pretty  frequently 
preserved,  while  that  of  the  mother  is  exposed  to  much  greater  risks. 
Upon  this  subject  it  may  be  established  as  a  general  rule,  that,  for 
the  woman,  the  danger  is  the  greater  as  the  pregnancy  is  the  more 
advanced,  and  that  the  converse  is  true  in  respect  to  the  child. 
External  hemorrhage  is  always  less  redoubtable  than  internal ;  be- 
cause, in  the  latter,  the  evil,  when  discovered,  is  often  beyond  the 
resources  of  art,  while  it  is  easy  to  recognize  (he  former  from  ita 


FLOODING.  373 

very  commencement.  Where  the  flow  takes  place  from  the  cord  or 
placenta,  the  life  of  the  foetus  is  more  seriously  njenaced  than  that 
of  the  mother,  and  vice  versa  as  to  uterine  hemorrhage,  properly  bo 
called. 

The  danger  is  not  to  be  estimated  by  the  quantity  of  blood  that 
i»  lost,  but  rather  by  the  effect  produced  by  it  upon  the  system  in 
general.  There  are  women,  who,  other  things  being  equal,  are 
\ed  to  the  verge  of  the  grave  by  the  loss  of  a  pound  of  blood,  while 
others  lose  double  or  triple  the  quantity  without  being  seriously 
incommoded  by  it ;  and  it  is  not  requisite  for  me  to  say  that  those 
who  are  strong,  sanguine,  and  robust,  suffer  from  it  less  than  such  as 
are  lymphatic,  weakly  and  anemic. 

874.  Even  although  we  should  be  so  fortunate  as  to  allay  the 
storm,  and  prevent  the  death  of  the  patient  in  a  case  of  profuse 
flooding,  there  would  still  be  reason  to  dread  relapses  that  would 
become  more  and  more  dangerous,  general  or  local  infiltrations, 
chronic  inflammations  of  the  womb,  peritoneum  pleura  and  peri- 
cardium, and  nervous  affections  of  all  sorts ;  as  to  the  dangers  of 
the  moment,  they  are  estimated  by  the  severity  of  the  symptoms 
under  notice  at  the  time.  While  ever  the  debility  is  not  great,  the 
pulse  retains  some  strength  and  hardness,  and  the  colour  of  the  skin 
and  features  of  the  countenance  remain  without  any  too  evident 
alteration,  the  flooding  need  not  excite  our  alarm ;  on  the  contrary, 
there  is  not  a  moment  to  lose  where  the  face  grows  pale,  the  extre- 
mities become  cold,  the  sight  grows  dim,  the  pulse  weaker,  tremu- 
lous, and  irregular ;  finally,  but  little  hope  remains  where  lipothymia, 
syncope  and  convulsions  supervene. 

876.  Notwithstanding  that  the  death  of  the  foetus  is  one  of  the 
ordinary  consequences  of  hemorrhage  occurring  in  the  four  or  five 
first  months  of  pregnancy,  and  that  at  later  stages  it  becomes  most 
generally  necessary  to  empty  the  uterus,  it  would  however  be  wrong 
to  conclude  that  a  happier  termination  of  it  can  never  be  obtained. 

Indeed,  all  observers  have  remarked  that  slight  floodings,  es- 
pecially those  occurring  in  the  first  stage  of  pregnancy,  when 
arrested  by  a  well  understood  mode  of  treatment,  sometimes  permit 
the  ovum  to  continue  its  evolutions,  and  the  footus  to  live  and  grow 
until  its  natural  term ;  the  blood  has  been  seen  to  flow  even  to  tlie 
extent  of  exciting  fears  for  the  woman's  life,  and  yet  abortion  not 
to  take  place  (4G0);  I  attended  a  young  lady  who  was  seized  with 
a  profuse  hemorrhage  in  the  third  month  of  her  second  pregnancy, 
who  lost  more  than  two  pounds  of  blood  in  the  space  of  thirty-six 
hours,  and  notwithstanding  did  not  miscarry ;  M.  Desormeaux  men- 
tions another  case,  where  the  blood  flowed  with  such  force  that  it 


374  DYSTOCIA. 

was  necessary  to  have  recourse  to  the  tampon^  and  where  the  preg- 
nancy, nevertheless,  went  to  its  full  term. 

876.  Uterine  hemorrhage  is  cured  in  three  ways. 

1.  The  blood  that  escapes  externally  sometimes  becomes  itself 
the  remedy  of  the  evil  it  constitutes,  disengorges  the  uterus,  destroys 
the  molimen^  removes  the  congestion,  and  permits  the  equilibrium 
to  establish  itself  naturally ;  here,  the  flow  may  have  been  effected 
at  the  expense  of  the  cervix,  the  vagina,  or  the  inferior  portion 
of  the  womb,  and  may  not  have  destroyed  the  principal  adherences 
of  the  ovum,  which  remains  uninjured,  and  thus  is  but  slightly  dis- 
turbed in  regard  to  its  development ;  or  the  placenta,  although  par- 
tially detached  by  the  blood  that  exudes  from  its  external  surface, 
continues  to  resist,  the  hemorrhage  stops,  and,  as  in  the  other 
case,  the  child's  life  is  preserved. 

2.  In  other  cases,  the  flooding,  after  it  has  continued  for  a  longer 
or  shorter  time,  ceases  ;  the  ovum,  although  detached  and  more  or 
less  altered,  is  not  expelled,  and  remains  in  the  uterus  for  a  period 
that  is  variable. 

3.  It  most  frequently  happens  that  the  contractions  of  the  uterus 
are  brought  into  play,  and,  in  these  cases,  we  can  rely  only  upon  abor- 
tion, delivery,  turning,  or  the  forceps,  to  save  the  patient  from  the 
dangers  with  which  she  is  threatened. 

Puzos  has  maintained  that,  when  the  flow  is  once  arrested,  the 
parts  may  contract  new  adhesions :  a  case  by  Noorthwyck,  that  of 
his  own  wife,  lias  been  supposed  to  confirm  this  opinion  ;  but  upon 
careful  reflection,  numerous  doubts  soon  occur  to  any  impartial  and 
unprejudiced  mind  as  to  the  value  of  this  fact. 

According  to  Pasta,  whenever  the  union  of  the  ovum  with  the 
womb  is  destroyed  by  the  flow  of  blood,  it  is  impossible  for  it  to  be 
re-established.,  and  when  abortion,  or  labour,  or  at  least  the  death  of 
the  foetus  do  not  follow  flooding,  it  is  because  the  hemorrhagic 
excitement  takes  place  in  some  part  beyond  the  limits  of  the  pla- 
centa. 

877.  The  following  is  what  observation  has  demonstrated  :  while 
the  blood  is  endeavouring  to  glide  towards  the  os  uteri,  a  more  or 
less  extensive  portion  of  the  placenta  or  anhistous  membrane  be- 
comes fully  saturated  with  it ;  first  one  clot  forms,  then  a  second,  then 
a  third;  and  these  several  layers,  of  various  thickness,  soon  become 
sufllciently  numerous,  provided  the  energy  of  the  hemorrhagic 
aflluxion  becomes  diminished,  to  exert  such  a  degree  of  pressure  as  to 
reluiji  the  blood  within  its  own  vessels ;  it  is  not  by  stopping  up 
largo  openings,  by  filling  large  vascular  trunks,  but  by  being  plas- 
<ered  against  the  pores  of  the  womb,  that  coagula  are  enabled  to  sus- 


FLOODING,  375 

pend  a  hemorrhage  ;  the  same  mechanism  by  which  they  succeed  in 
putting  a  stop  to  cpistaxis,  when  they  accumulate  within  the  cavities 
of  the  nose. 

878.  Provided  these  coagula  are  not  very  extensive,  the  ovum 
continues  to  live,  like  a  tree  from  which  one  or  more  of  the  roots 
have  been  removed  :  the  fluid  part  disappears  by  means  of  imbibi- 
tion, and  the  fibrinous  layers  becoming  drier  and  drier,  and  less  and 
less  evident,  remain,  sometimes,  until  labour  takes  place,  although 
the  points  which  they  separate  are  not  re-united.  At  the  Maternite 
at  Tours,  I  saw  a  young  woman  who  was  thrice  seized  with  slight 
flooding,  at  intervals  of  a  fortnight,  in  the  two  last  months  of  her 
first  pregnancy.  There  was  nothing  peculiar  in  her  labour ;  but 
there  were  found  on  the  surface  of  the  placenta,  three  distinct  layers, 
about  the  size  of  a  three  livres  piece ;  one  of  these  layers,  which  was 
very  near  the  edge  of  the  placenta,  was  composed  of  a  clot  that  was 
still  red,  of  a  lenticular  shape,  and  with  difficulty  separable  from  the 
after-birth ;  the  second  was  composed  of  a  fibrinous  concretion,  much 
firmer  and  scarcely  coloured  at  all ;  the  third  looked  more  like  a 
sort  of  cicatrix.  Is  it  not  evident  that  these  three  points  corresponded 
to  the  seat  of  the  three  hemorrhages  that  had  taken  place  ante- 
cedently to  the  occurrence  of  the  labour  ? 

879.  Treatment.  It  may  with  truth  be  said  that  the  uterine 
hemorrhages  of  pregnant  women  are  diseases  which  require,  on  the 
part  of  the  practitioner,  the  greatest  coolness,  knowledge  and  skill ; 
indeed,  in  presence  of  such  accidents,  a  few  seconds,  more  or  less, 
often  decide  as  to  the  life  or  death  of  two  beings,  equally  dear ;  such 
are  the  cases  where  it  imports  us  to  know  how  to  choose  the  remedy 
and  apply  it  properly,  and  where  a  distrustful  timidity  might  become 
equally  fatal  with  imprudence  and  rashness. 

The  means  to  which  we  can  have  recourse  are  extremely  nume- 
rous ;  some  of  them  are,  to  a  certain  extent,  applicable  to  all  cases 
indiscriminately,  and  others  are  to  be  employed  only  under  peculiar 
circumstances. 

880.  Rest,  low  diet,  a  horizontal  posture  upon  a  hair  mattress, 
rather  than  upon  a  feather  bed,  in  a  chamber  which  ought  to 
be  darkened  rather  than  too  much  hghted,  quiet  and  not  noisy,  cool, 
and  well  ventilated,  rather  tlian  hot  and  close,  with  diluting  or  cold  aci- 
dulous drinks  very  frequently  suffice  when  early  recourse  is  had  to 
them,  in  moderate  cases  of  hemorrhage :  if  the  woman  is  strong  or 
sanguine,  and  especially  if  there  have  been  precursory  symptoms,  if 
there  are  rigors,  and  the  state  of  the  pulse  warrants  it,  six  or  eight 
ounces  of  blood  may  be  drawn  from  the  arm.  When  these  slight 
succours  do  not  succeed  at  once,  and  where  there  has  been  no  pre- 


376  DYSTOCIA. 

cursory  molimen,  and  the  woman  is  naturally  weak,  we  have  re- 
course to  revulsives,  and  to  external  refrigerants.  We  prescribe 
manuluvia,  either  simple  or  containing  mustard,  dry  friction  of  the 
arms,  the  breast  and  along  the  spine,  and  apply  large  cups  to  the 
breasts ;  aspersions  are  made  upon  the  abdomen  and  inner  part  of 
the  thighs,  with  cold  water,  either  alone  or  with  the  addition  of  vine- 
gar, ether,  or  ammoniac,  &c. ;  compresses  wetted  withthe  same 
liquids,  or  with  ice  water,  may  also  be  applied  to  the  same  parts. 
Burns  praises  the  effects  of  alum ;  Duncan  and  Rigby  seem  to  have 
derived  great  advantages  from  the  use  of  opium  and  sugar  of.  lead 
(acetate  of  lead),  which  had  previously  been  recommended  by  Et- 
muller,  &c.  and  is  frequently  employed  by  Dewees  ;  the  digitalis  is 
also  recommended  by  many  of  the  English  physicians  ;  but  these  va- 
rious articles  are  rarely  made  use  of  in  France.  Rhodion,  Hamilton, 
and  some  others  have  recommended  the  application  of  tight  ligatures 
to  the  limbs.  A  practice  that  seems  to  me  to  deserve  the  attention  of 
practitioners  is  the  application  of  a  sinapism  between  the  shoulders  ; 
1  have  made  use  of  it  often  enough,  and  in  cases  sufficiently  various, 
to  enable  me  to  affirm  that  it  is  one  of  the  most  powerful  and  most 
useful  revulsives  that  can  be  recommended.  MM.  Trastour,  La- 
roche,  Nivert,  and  several  young  physicians  who  have  seen  me  em- 
ploy it,  or  put  it  in  practice  themselves,  have  already  made  mention 
of  it  in  their  theses.  I  have  elsewhere  stated  the  anatomical  and 
physiological  considerations  by  which  I  was  led  to  its  employ- 
ment. I  resort  to  it  both  in  the  first  months  of  pregnancy  and 
during  labour,  as  also  in  the  interval  betwixt  these  periods  ;  and  the 
effect  has  always  been  extremely  prompt.  A  young  woman,  nine- 
teen years  of  age,  was  brought  to  the  Clinique  Externe  of  the  School 
of  Medicine  towards  the  close  of  1825  ;  she  was  about  three  months 
gone  with  child,  and  had  been  flooding  for  twelve  hours  ;  we  tried 
the  remedies  indicated  higher  up,  but  the  flow  continued  neverthe- 
less to  increase  until  evening';  being  then  alarmed  by  her  extreme 
weakness  and  the  appearances  of  approaching  syncope,  I  applied  a 
mustard  cataplasm  to  her  back  ;  in  a  quarter  of  an  hour  the  dimi- 
nution of  the  hemorrhagy  was  evident ;  it  soon  became  a  mere 
draining,  which  continued  until  the  next  day,  when  the  ovum  was 
expelled. 

There  ought  to  be  nothing  surprising  in  such  a  result,  when  we 
reflect  witli  what  ease  people  in  tlie  country  sometimes  put  a  stop 
to  cpistaxis,  by  placing  a  key,  or  some  pieces  of  linen,  or  the  like, 
wetted  with  cold  water  betwixt  the  shoulders,  and  with  what  rapidity 
sympathetic  irradiations  are  brought  into  play  by  the  action  of  mus- 
tard.    Nevertheless,  it  would  be  unreasonable  to  think  that  the  action 


FLOODING.  377 

of  this  medicament  is  infallible,  and  that  it  ought  to  be  employed  in 
all  cases.  Reason  indicates  that  it  would  be  injurious  rather  than 
useful  where  the  flooding  is  attended  with  a  general  reaction  of  the 
system,  and  the  symptoms  of  the  hemorrhagic  effort  continue  in 
full  force ;  both  in  pregnancy  and  during  labour,  as  the  placenta 
is  to  a  great  extent  detached,  and  its  expulsion  inevitable,  it  might 
serve  to  diminish  the  impetuosity  of  the  affluxion,  but  there  would 
be  little  wisdom  in  relying  upon  it  to  completely  suppress  a  he- 
morrhagy  that  had  already  become  serious  and  alarming. 

881.  The  tampon.  Doubtless  one  of  the  first  ideas  to  occur  to  the 
mind  upon  observing  a  flow  of  blood  from  the  womb,  was  to  stop  up  the 
orifice  of  that  organ  ;  however,  notwithstanding  what  Costa  says  upon 
the  subject,  the  use  of  the  tampon  was  hardly  mentioned  in  the  science 
until  since  the  times  of  Madame  Bourgeois,  o£  P.  Portal,  F.  HofT- 
mann,  and  Smellie.  If  we  may  confide  in  Leroux,  the  tampon  is  an 
heroic  remedy,  which  is  almost  always  followed  by  success  ;  accord- 
ing to  the  modern  classics,  on  the  contrary,  it  is  rarely  an  useful, 
and  most  frequently  a  dangerous  remedy,  that  ought  to  be  proscribed 
from  sound  practice.  Amongst  others,  M.  Demangeon,  who  has 
been  well  combated  by  M.  Gardien,  ha.3  expressed  himself  strongly 
against  the  tampon,  which,  in  his  opinion,  can  only  serve  to  augment 
the  dangers  of  the  disease.  Rigby  and  Merriman  scarcely  make 
mention  of  it.  Specious  arguments,  theoretical  prejudices,  excep- 
tional cases  generalized,  and  false  reasonings,  comprise,  notwith- 
standing, all  that  has  been  brought  to.  bear  against  the  innumerable 
facts  that  have  been  reported  by  an  infinite  number  of  authors  :  in 
fact,  it  is  not  possible,  after  reading  the  work  of  Leroux,  to  partici- 
pate in  the  fears  that  are  attempted  to  be  awakened  by  the  antago- 
nists of  the  tampon,  or  in  common  with  Burns,  Mesdames  Boivin 
and  Lachapelle,  and  Dr  Dewees,  not  to  consider  it  as  one  of  the 
most  powerful  means  of  rescuing  women  from  the  dangers  of  a 
serious  attack  of  flooding. 

882.  It  ought  not  upon  this  account  to  be  said  that  it  never  can 
be  injurious.  The  tampon,  like  all  important  therapeutic  resources, 
is  a  weapon  of  protection  in  the  hands  of  a  skilful  practitioner,  but  it 
may  become  a  murderous  one  in  those  of  an  ignorant  person.  For 
example,  it  would  be  imprudent  to  make  use  of  it  at  the  commence- 
ment of  a  flooding,  before  the  symptoms  of  plethora  have  been  dis- 
sipated, or  where  the  blood  is  being  eft'used  within  the  interior  of 
the  membranes  with  the  uterus  in  a  state  of  inertia  ;  for  in  such  a 
condition  it  could  not  fail  to  augment  the  excitement,  or  by  retain- 
ing the  blood  in  the  womb,  favour  the  indefinite  distention  of  the 
parietes  of  that  organ.     Nevertheless,  it  has  not  as  yet  been  very 

2X 


378  DYSTOCIA. 

positively  demonstrated,  that  even  here  it  would  not  be  more  fre- 
quently useful  than  hurtful ;  reasoning,  which  accords  vi'ith  a  pretty 
considerable  number  of  facts,  leads  me  to  believe,  along  with  M. 
Chevreul,  that  it  affords,  perhaps,  one  of  the  surest  means  of  forcing 
the  uterus  to  contract,  or  arouse  it  from  its  lethargy ;  this  is  the 
property,  even,  which  renders  it  redoubtable  where  we  are  fearful 
of  facilitating  the  expulsion  of  the  ovum,  and  which  makes  it  impro- 
per to  resort  to  it  until  after  we  have  ascertained  the  inefficacy  of 
other  modes  of  treatment. 

883.  It  is  composed  in  very  various  ways  :  many  persons  content 
themselves  with  filling  the  vagina  with  tow,  lint,  old  linen,  sponge, 
&c.  Dewees  says  it  is  never  necessary  to  carry  the  tampon  as  far 
as  the  OS  uteri ;  there  are  some  who  prefer  a  small  bag,  or  sort  of 
purse,  filled  with  astringent  substances ;  but  the  simplest  method, 
which  also  is  that  adopted  by  M.  Desormeaux,  consists  in  making 
a  kind  of  sac  with  fine  linen  well  greased  with  cerate,  and  which  is 
introduced  empty  as  far  as  the  os  tineas,  to  be  afterwards  filled 
with  little  rolls  of  lint  or  tow,  or  some  such  substance,  and 
then  secured  v/ith  a  T  bandage.  The  oil  in  which  Burns  advises 
us  to  soak  the  tampon  appears  to  me  to  be  of  no  other  use  but 
to  favour  its  introduction.  Vinegar,  and  oxycrate,  recommended  by 
others,  are  of  less  doubtful  value,  although  their  styptic  action  is 
soon  annihilated  by  the  coagula,  and  by  the  flow  of  the  blood ; 
moreover,  it  is  a  mechanical  barrier  and  not  a  pharmaceutic  sub- 
stance by  which  we  attempt  to  oppose  the  hemorrhagy.  It  is  a 
real  stopper,  which,  by  closing  up  the  passage  to  the  blood,  compels 
it  to  coagulate  by  little  and  little,  and  as  it  becomes  concrete,  to  com- 
press and  shut  up  the  exhalent  orifices  that  furnish  the  fluid  ;  on  the 
other  hand,  by  its  quality  as  a  foreign  body,  it  excites  the  cervix, 
and  changes  the  vitality  of  the  womb,  whoso  contractility  it  arouses, 
whose  reaction  it  recalls,  to  such  a  degree  as  soon  to  occasion  the 
expulsion  of  the  ovum. 

If  it  is  to  succeed,  the  blood  ceases  to  flow  from  the  vulva,  the 
general  symptoms  are  gradually  allayed,  the  hypogastrium  becomes 
more  firm  without  increasing  in  size,  and  provided  the  womb  is 
not  to  be  emptied,  the  woman  only  experiences  a  feeling  of  tenes- 
mus, straining  and  weight  in  the  pelvis,  and  sometimes  slight  colic 
pains ;  while,  in  the  opposite  case,  pretty  smart  pains,  and  real 
contractions  of  the  womb  supervene ;  in  consequence  of  which  the 
clots,  the  tampon,  and  the  product  of  the  conception  are  all  expelled 
one  after  another  from  the  genital  organs. 

In  some  women  it  is  followed  by  such  a  degree  of  uneasiness, 
even  although  there  may  bo  no  uterine  contractions,  that  they  insist 


FLOODING.  379 

upon  its  being  removed ;  in  general,  their  entreaties  should  he  re- 
sisted, provided  no  evidences  of  internal  hemorrhage  are  discovered, 
unless,  indeed,  the  pain  is  so  acute  as  to  give  rise  to  certain  nervous 
affections,  or  convulsions  ;  complaints  in  these  cases  are  rather  to 
be  desired  than  feared.  After  some  time  the  functions  are  seen  to 
return  to  their  natural  stale ;  and,  in  order  to  avoid  the  risk  of  a 
return  of  the  flooding,  the  tampon  is  left  in  situ  as  long  as  possible, 
at  least  for  several  hours,  or  even  a  whole  day  ;  then,  when  it  is 
no  longer  considered  to  be  indispensably  necessary,  the  T  bandage 
only  is  removed,  for  the  tampon,  being  no  longer  kept  in  the  organs 
by  an  external  force,  it  escapes  spontaneously  and  gently. 

884.  Dilatation  of  the  os  uteri,  and  rupture  of  the  membranes. 
Before  proceeding  to  forced  delivery,  Puzos  recommends  the  trial 
of  a  practice  which  is,  in  his  opinion,  much  more  simple,  and  par- 
ticularly much  more  consonant  to  the  nature  of  the  organism  ;  in- 
troduce, says  he,  first  one,  then  two,  then  three  fingers  into  the 
orifice,  which  you  should  titillate  and  irritate,  but  very  gently  ;  and 
you  will  often  find  that  this  alone  will  suffice  to  stop  the  hemorrhagy, 
and  to  induce  the  womb  to  contract.  If  this  does  not  suffice,  begin 
to  dilate  it,  enlarge  it  with  all  the  care  and  gentleness  that  the  seve- 
rity of  the  symptoms  will  admit  of  your  using,  and  if  you  still  do  not 
succeed,  perforate  the  membranes,  and  the  vacuum  that  will  take 
place  in  the  membranes  will  rarely  fail  to  be  followed  by  the  expul- 
sive contractions  of  the  womb.  You  will  have,  it  is  true,  a  prema- 
ture dehvery,  but  which  will  be  less  dangerous  both  to  the  mother 
and  the  child  than  if  the  practitioner  had  undertaken  to  deliver 
the  foetus. 

885.  This  conduct  is  particularly  adapted  to  cases  where  hem- 
orrhage takes  place  during  labour,  or  where  the  pregnancy  is  very 
much  advanced,  and  the  placenta  is  not  attached  near  to  the  neck. 
Notwithstanding,  it  is  evident  that  with  the  exception  of  the  rupture 
of  the  membranes,  the  tampon  fulfils  pretty  nearly  the  same  indica- 
tions, and  that  where  the  flooding  is  violent  it  would  be  wrong  to  act 
with  so  much  reserve,  and  not  to  terminate  the  delivery  as  soon  as 
possible. 

Forced  delivery.  When  a  labour  proceeds  with  a  certain  degree 
of  regularity,  notwithstanding  the  hemorrhage  may  continue,  and  the 
powers  of  the  woman  may  diminish  too  rapidly,  it  generally  suffices 
to  accelerate  the  contractions  as  hath  been  mentioned,  and  to  en- 
gage the  woman  to  keep  up  her  courage  and  use  her  best  efforts  to 
enable  the  womb  to  get  rid  of  its  contents  as  well  as  to  put  a  stop  to 
the  flooding.  •  Provided,  on  the  other  hand,  the  infrequency  of  the 
pains  does  not  permit  him  to  rely  upon  the  powers  of  the  economy, 


380  DYSTOCIA. 

the  accoucheur  should  hasten  to  deliver  the  child.  If  the  head  be 
already  engaged  in  the  superior  strait,  and  the  os  uteri  sufficiently 
open,  and  a  fortiori  if  it  have  already  reached  the  excavation,  it 
should  be  seized  with  the  forceps  :  otherwise  the  child  should  be 
turned  ;  but  in  order  to  admit  of  the  hand  being  carried  into  the 
womb,  the  orifice  must  have  reached  a  certain  degree  of  dilatation, 
or  at  least  be  in  a  very  dilatable  state.  Therefore,  it  is  only  in  the 
last  stages  of  pregnancy,  and  where  nature  or  the  means  hereto- 
fore pointed  out  have  forced  the  labour  to  begin,  that  we  may 
resort  to  this  method,  which  is  particularly  applicable  to  cases  of 
hemorrhagy  from  implantatidn  of  the  placenta  over  the  cervix  uteri. 
Happily,  when  there  is  a  flooding,  the  orifice  is  commonly  very  soft, 
and  admits  of  a  ready  passage.  Moreover,  it  is  manifest  that  where 
the  danger  is  pressing,  it  would  be  better  to  make  use  of  some 
violence  in  overcoming  the  resistance,  than  to  abandon  the  woman 
to  the  so  frequently  fatal  chances  of  an  overwhelming  flooding. 

886.  The  termination  of  the  labour  should  never,  under  any  pre- 
text, be  left  to  the  powers  of  nature,  when  the  hemorrhagy  is  in- 
contestably  occasioned  by  the  insertion  of  the  placenta  upon  the  os 
uteri. 

In  this  particular  case,  many  practitioners  have  recommended, 
that  as  soon  as  the  fingers  have  got  within  the  os  uteri,  we  should 
try  to  find  that  part  of  the  edge  of  the  placenta  that  is  nearest,  so 
as  to  pass  up  the  hand  in  that  direction  ;  others  have  thought  that 
in  difficult  cases,  or  where  there  is  no  time  to  temporise,  it  would  be 
better  to  neglect  this  minute  research,  and  to  perforate  or  rupture 
that  point  of  the  ovum  that  corresponds  to  the  orifice,  so  as  instantly 
to  lay  hold  on  the  child's  feet.  The  former  of  these  two  modes  of 
practice  would  occupy  too  much  time  ;  and  the  latter  would  not 
fail  to  augment  very  greatly  the  violence  of  the  hemorrhagy,  and 
seriously  endanger  the  life  of  the  fcetus,  should  its  extraction  hap- 
pen to  be  tedious  or  difficult.  Besides,  the  child  would  have  to  be 
withdrawn  through  the  opening  in  the  placenta,  which,  being  pulled 
downwards  by  the  shoulders  or  head,  would  necessarily  raise  great 
obstacles  to  the  operation. 

The  method  followed  by  P.  Portal,  M.  Dubois,  &:.c.  is  in  all  re- 
spects to  be  preferred.  Without  any  regard  to  the  edge  of  the 
placenta,  the  hand,  after  reaching  the  os  uteri,  is  to  be  first  carried 
in  front,  and  then  to  the  right  of  the  woman  if  it  be  the  left  hand, 
and  to  her  left  if  it  be  the  right  hand  that  is  made  use  of,  and  in 
less  than  a  second,  the  membranous  part  of  the  ovum  is  reached, 
and  mu.st  be  perforated  ;  the  feet  arc  now  promptly  seized,  and  the 
fa5tus  may  be  delivered  before  the  after-birth. 


FLOODING.  381 

887.  In  the  other  species  of  hcmorrhagy,  when  the  turning  has 
been  effected,  and  the  hips  are  at  the  vulva,  it  seems  to  be  wise, 
provided  there  be  no  inertia  of  the  womb,  to  leave  the  closing  of 
the  labour  to  nature,  whereas,  in  cases  of  implantation  over  the 
cervix,  when  the  operation  is  once  begun  it  cannot  be  terminated 
too  soon.  The  reason  of  this  difference  strikes  us  at  once:  in  the 
first  mentioned  case,  as  the  omphalo-placental  circulation  continues 
to  go  on,  the  life  of  the  child  is  not  compromitted,  and  that  of  the 
mother  is  no  longer  in  danger  as  soon  as  the  blood  ceases  to  flow ; 
in  the  second,  the  functions  of  the  placenta  ceasing,  a  few  moments 
of  delay  might  occasion  the  death  of  the  foetus.  , 

Is  it  necessary  for  me,  in  closing,  to  state  that  the  reader  must 
look  to  the  articles  on  abortion  and  delivery  of  the  placenta  for  the 
details  which  I  cannot  introduce  here  ? 

§  II.  Of  convulsive  dystocia. 

The  agitation,  the  agonies  of  a  woman  in  the  midst  of  the  most 
violent  labour  pains  are  sometimes  carried  to  such  an  extent,  that  to 
have  been  witnesses  of  them  is  sufficient  to  make  us  feel  that  such  a 
state  borders  closely  upon  the  convulsive  affections,  and  convince  us 
that  convulsions  must  be  frequently  met  with  in  women  in  labour. 

The  convulsions  of  pregnant  women,  like  those  of  other  women, 
may  be  general  or  local ;  affect  only  one  or  all  the  limbs ;  the  face  or 
any  other  part  separately  ;  or  they  may  bring  into  play  all  the  mus- 
cles of  the  life  of  relation :  most  commonly  none  but  the  muscles 
that  are  habitually  subject  to  the  will  are  affected ;  but  in  certain 
cases,  those  viscera  which  contain  a  muscular  membrane  are  also 
seized.  Thus  the  pharynx,  the  cesophagus,  the  stomach,  the  intes- 
tines, the  bladder,  the  uterus  itself,  the  heart,  and  especially  the  dia- 
phragm, are  at  times  violently  tormented  by  them. 

Hysteria,  epilepsy,  catalepsy,  and  the  convulsions  produced  by 
some  material  lesion,  such  as  a  phlegmasia,  or  any  disease  of  the 
encephalon  or  its  meninges,  or  of  the  general  nervous  system,  ap- 
pear pretty  frequently,  and  sometimes  become  aggravated  during 
the  course  of  pregnancy  ;  but  it  is  to  be  observed  that  the  three  first 
rarely  manifest  themselves  during  labour.  Moreover,  in  these  cases 
the  disease  is  complicated  by  the  state  of  gestation,  and  that  is  not 
what  is  generally  understood  by  the  convulsions  of  pregnant  women." 

888.  Puerperal  convulsions,  also  called  apoplectic  convulsions, 
hysterical  apoplexy^  milk  apoplexy^  sympathetic  apoplexy,  eclamp- 
sia of  labour,  differ  from  other  diseases,  in  that  they  are  evidently 
connected  with  the  state  of  pregnancy,  which  they  complicate. 

889.  Their  proximate  cause  is  always  located  in  the  brain,  and, 


382  DYSTOCIA. 

consequently,  I  do  not  perceive  the  use  of  dividing  them  into  sym- 
pathetic and  idiopathic  convulsions.  This  proximate  cause,  doubt- 
less, is  an  irritation,  or  stimulus,  which  reacts  upon  the  whole 
nervous  system,  but  whose  nature  appears  to  be  extremely  variable : 
sometimes  it  is  a  precedently  irritated  point  in  the  brain  which  invites 
the  fluids  into  that  organ,  which  thus  becomes  a  centre  of  fluxion  ; 
sometimes,  on  the  contrary,  the  fluids  themselves,  by  being  deter- 
mined towards  the  brain  in  too  large  quantity,  produce  a  state  of 
congestion  therein,  and  in  consequence  thereof,  a  convulsive  re-ac- 
tion. In  this,  as  in  the  other  case,  the  remote  causes  are  very  nume- 
rous. There  are  predisposing  and  determining  causes.  Although 
eclampsia  is  observed  at  all  seasons,  at  every  age,  in  all  classes  of 
society,  and  under  all  temperatures,  it  is,  notwithstanding,  true  to 
say,  that  strong  persons,  those  who  are  plethoric,  of  a  dry  fibre,  very 
animated  countenance,  short  neck,  abundantly  and  frequently  re- 
gulated, nervous,  delicate,  irritable,  subject  to  nervousness,  and 
young  women  in  the  first  pregnancy,  are  more  liable  to  them  than 
others. 

Air  that  is  impure,  charged  with  odours,  and  too  rarely  renewed  ; 
the  summer  heats,  too  high  an  artificial  temperature,  anger,  grief, 
vexation,  some  unexpected  news,  joy,  and  all  the  vivid  emotions ; 
loss  of  sleep,  frequenting  of  balls  and  theatres ;  labouring  at  night ; 
the  abuse  of  baths,  of  hot  drinks,  of  cofiee,  tea,  spirituous  liquors,  and 
spiced  or  high-tasted  dishes ;  a  succulent  regimen,  and  whatever  in- 
creases the  afflux  of  blood  towards  the  head ;  the  presence  of  a 
great  quantity  of  water  in  the  membranes,  or  of  several  children  in 
the  womb  ;  rigidity  or  extreme  sensibility  of  the  fibres  of  that  organ  ; 
hardness  or  spasmodic  contraction  of  the  neck  of  the  womb  ;  the 
pressure  which  it  exerts  upon  the  surrounding  vessels  and  nerves ;  the 
thrusting  of  the  stomach  upwards ;  coition ;  the  suppression  of  an 
issue  or  any  habitual  discharge ;  the  use  of  corsets,  and  too  tight 
dresses  ;  and  want  of  exercise,  &c.  have  been  ranked  among  the 
causes  of  eclampsia.  To  these  have  been  also  added,  infiltration  of 
the  limbs  or  leucophlegmasia,  living  in  hot  countries,  indulging  in  too 
much  sleep,  leisure,  the  use  of  alcoholic  elixirs  and  tinctures  ;  the 
habit  of  lying  long  in  bed,  atmospheric  vicissitudes,  and  almost  all 
the  common  causes  which  the  authors  never  fail  to  recall  upon  the 
occasion  of  each  disease  they  describe,  those  causes  which  seem 
to  produce  all  the  evils  because  they  do  not  necessarily  create  any 
one  of  them. 

890.  No  one  can  deny  that  such  circumstances  have  sometimes 
produced  eclampsia  ;  but  it  is  also  undeniable  that  it  often  comes  on 
without  its  being  possible  to  assign  any  satisfactory  reason  for  it. 


CONVULSIONS.  383 

Convulsions  appear  most  commonly  towards  the  end  of  pregnancy, 
and  their  most  common  occasional  cause  is  labour ;  they  may  then 
depend  upon  some  obstacle  which  by  obstructing  the  escape  of  the 
fcEtus,  soon  produces  a  general  disturbance  of  the  system  ;  or  upon 
a  simple  irritation  that  reacts  upon  the  whole  economy  ;  or,  also,  a 
repulsion  of  the  fluids  towards  the  interior  of  the  body,  occasioned 
by  the  eflbrts  which  the  woman  is  compelled  to  make.  They  may 
also  be  the  consequence  of  an  attack  of  hemorrhage,  or  of  exhaus- 
tion, or  the  symptom  of  some  rupture,  &c.  Many  practitioners, 
among  whom  are  M.  Desormeaux  and  Madame  Lachapelle,  have 
observed  that  eclampsia  sometimes  prevails  almost  epidemically. 
"  When  one  of  our  women  had  been  seized  with  convulsions, 
we  rarely  failed,"  says  Madame  Lachapelle, "  soon  afterwards  to  have 
several  others  in  the  same  state."  A  tendency  to  imitation  would 
be  here  insufficient  to  account  for  the  fact,  and,  besides,  could  not 
be  applicable  to  cases  occurring  out  of  the  public  establishments,  in 
private  practice,  or  in  those  singular  epidemics  that  have  been  so 
often  observed. 

891.  Signs.  The  attack  of  eclampsia  is,  in  some  women,  an- 
nounced by  various  precursory  symptoms,  such  as  flushes  of  heat 
about  the  head,  giddiness,  confusion  of  ideas,  hallucinations,  indis- 
position to  move,  uneasiness  in  the  limbs,  a  dull  or  frightened  look, 
redness  of  the  conjunctiva,  or  of  the  whole  countenance,  headach, 
vertigo,  stammering,  vivid  brightness  of  the  eyes,  irregularity  of 
the  pulse,  slight  convulsive  motions  of  the  muscles  of  the  face, 
subsultus  of  the  muscles  of  the  extremities  ;  but  it  is  often,  also, 
found  to  appear  in  a  sudden  and  unexpected  manner,  and  to 
attack  at  once,  with  the  most  alarming  symptoms.  The  woman 
suddenly  becomes  insensible,  and  seems  to  revive  for  a  moment  only 
to  fall  again  into  the  most  violent  agitation  ;  the  limbs  writhe,  con- 
tract, become  flexed  and  extended  with  astonishing  strength  and 
celerity  ;  the  body  is  bent  backwards,  as  if  the  head  and  heels  were 
about  to  approach  each  other ;  the  hands  are  powerfully  directed 
towards  the  breast  or  the  epigastrium,  which  they  strike,  and  some- 
times appear  to  tear  with  rage  ;  the  features  of  the  face  become  dis- 
torted and  convulsed;  the  lips,  which  are  drawn  in  various  directions, 
move  in  the  most  singular  manner;  the  eyes  roll,  are  agitated  and 
turned  up  under  the  orbits  ;  the  pulsation  of  the  carotids  and  tem- 
poral arteries  is  seen  through  the  skin ;  the  jugulars  swell ;  the  throat 
and  face  become  tumid,  and  almost  purple ;  the  eyes  seem  as  if  they 
would  start  out  of  the  head;  the  mouth  fills  with  water,  which  is  spirted 
sometimes  to  a  great  distance  upon  the  assistants  ;  the  tongue,  irre- 
gularly agitated,  is  often  pinched,  and  even  violently  bitten,  by  the 


384  DYSTOCIA. 

grinding  of  the  teeth  and  the  spasmodic  motions  of  the  jaws.  In  these 
terrible  moments  the  woman  is  truly  a  frightful  object,  and  highly 
deserving  of  pity  ;  the  diaphragm  by  its  rapid  contractions  gives  rise 
to  sobs,  and  an  appearance  of  suffocation,  and  forces  from  the  mouth 
and  nostrils  the  substances  accumulated  in  them.  The  stomach  and 
bowels,  the  bladder  and  uterus  itself,  when  they  become  the  seats  of 
such  motions,  produce  vomitings,  involuntary  expulsion  of  the  fasces 
and  urine,  and  sometimes  of  the  ovum,  with  an  extreme  prompti- 
tude ;  in  fine,  it  might  be  said  that  all  the  viscera  participate  in  the 
disordered  movements  of  the  limbs.  At  other  times,  the  face  and 
rest  of  the  body  pass,  so  to  speak,  with  the  rapidity  of  lightning, 
from  this  state  of  agitation  and  vivid  colour  into  the  most  perfect 
calm,  and  fall  into  a  mortal  paleness  ;  at  last,  and  more  or  less 
promptly,  the  congestion  of  the  brain  brings  on  coma,  which  gene- 
rally succeeds  the  attacks  of  syncope  and  insensibility. 

892.  The  duration  of  an  attack  is  not  less  variable  than  its  in- 
tensity ;  it  lasts  in  some  cases  only  from  ten  minutes  to  a  quarter  of 
an  hour  or  half  hour ;  whilst  in  others  it  continues  half  a  day  or 
even  twenty-four  hours ;  if  coma  supervenes,  it  may  prolong  the 
insensibility  for  several  days  and  terminate  in  a  complete  and  prompt 
restoration  to  health  ;  but  it  is  also  found  to  assume  all  the  charac- 
ters of  apoplexy,  and  occasion  the  death  of  the  patient.  It  also  some- 
times happens  that  certain  of  the  functions  remain  in  a  perverted  state 
after  the  cessation  of  the  convulsions  ;  sometimes  the  sight,  or  hear- 
ing, or  smell,  or  some  one  of  the  intellectual  faculties  appears  to  have 
suffered  the  severest  pressure  of  the  disease  ;  at  others,  there  are 
found  internal  lacerations  or  particular  eflfusions,  that  occasion  a 
deviation  from  the  natural  state  of  the  organism,  &c. 

When  the  woman  comes  to  herself,  fatigued  and  worn  out,  her 
limbs  bruised,  as  after  long  and  violent  exercise,  astonished  at  the 
situation  in  which  she  finds  herself,  she  is,  sometimes,  ignorant  of 
every  thing  that  has  taken  place,  can  scarcely  believe  what  is  told 
her,  and  has  no  knowledge  of  the  extraordinary  movements  execut- 
ed by  all  parts  of  her  frame,  or  the  violent  cries  she  has  uttered ; 
some  are  mentioned,  even,  who  have  been  delivered  without  know- 
ing it,  and  after  the  attack  was  over  could  not  understand  that  they 
were  really  delivered  ! 

On  the  parts  that  have  been  struck  with  considerable  force  wc 
afterwards  find  blackish  spots,  which  are  real  contusions,  attended 
with  more  or  less  pain. 

Whore  the  woman  recovers  her  senses  in  the  intervals  of  the 
paroxysms,  the  convulsions  have  been  denominated  epileptiform; 
in  the  contrary  case,  and  especially  where  they  are  accompanied 


CONVULSIONS.  385 

with  stertor  and  coma,  they  are  called  apoplectiform  or  eclampsic. 
This  division  can  be  of  use  no  further  than  this — viz.  that  the 
former,  which  are  more  easily  confounded  with  epilepsy  or  hysteria, 
are  rarely  so  dangerous  as  the  latter ;  but  in  fact  they  are  only  dif- 
ferent shades  of  the  same  affection. 

893.  The  examination  of  the  body  after  death  is  far  from  always 
giving  a  satisfactory  explanation  of  the  severity  of  the  symptoms. 
A  small  quantity  of  serum  in  the  ventricles  of  the  brain  ;  the  veins 
and  sinuses  of  the  brain  more  or  less  engorged  ;  the  meninges  and 
cerebral  substance  somewhat  red,  or  of  a  natural  appearance  ;  in 
some  cases  evident  traces  of  congestion,  or  a  slight  extravasation 
of  blood ;  but,  most  generally,  no  appreciable  lesion,  is  what  the 
unprejudiced  observer  finds  within  the  cranium.  Neither  have  the 
other  splanchnic  cavities  exhibited  any  alterations,  that  constantly 
occur  in  these  cases  ;  the  heart  is  flaccid  and  almost  empty  ;  the 
lungs  choked  up  or  pale  ;  a  few  ounces  of  citron- coloured  or  red- 
dish serum  in  the  serous  cavities,  are  the  principal  traces  left  by  the 
disease  in  the  abdomen  and  thorax. 

Without  being  rare,  eclampsia  is,  notwithstanding,  not  a  disease  fre- 
quently to  be  met  with,  since  Madame  Lachapelle  met  with  it  only  sixty- 
five  times  in  nearly  forty  thousand  pregnant  women  ;  the  prognosis  is 
in  general  unfavourable,  for  by  the  admission  of  that  lady,  in  spite  of  the 
most  rational  and  careful  treatment,  one  third  of  the  cases  proved  fatal. 
It  is  more  frequent  in  the  last  three  months  and  during  labour  than 
at  other  periods,  and  is  less  dangerous  when  it  occurs  after  delivery, 
or  previously  to  the  sixth  or  seventh  month  of  gestation.  J\ot  so 
serious,  cseteris  paribus,  when  occurring  during  labour,  as  before 
it,  it  is  less  so  in  proportion  as  the  labour  is  more  advanced  at  the 
moment  of  the  first  attack.  As  the  emptying  of  the  uterus  is  often 
the  only  means  of  putting  an  end  to  the  'convulsions,  it  is  evident 
that  the  danger  arising  from  them  will  be  in  a  direct  ratio  to  the 
difficulty  of  effecting  that  object ;  if  the  neck  of  the  womb  and  the 
head  of  the  foetus  are  disposed  in  such  a  way  as  to  make  it  an  easy 
matter  to  extract  the  child,  the  disease  may  be  considered  as  less 
alarming  than  if  the  orifice  is  still  hard  and  undilated.  Those  cases 
that  attack  women  who  are  hysterical,  epileptic,  or  endowed  with 
great  nervous  susceptibility,  or  whose  form  exposes  them  more  par- 
ticularly to  these  two  affections  ;  those  in  whom  the  paroxysms  are 
short,  or  separated  by  well  marked  intervals  of  calm,  and  of  restora- 
tion of  all  the  functions,  are  always  less  to  be  dreaded  than  such  as 
possess  no  analogy  with  an  anterior  nervous  state  of  the  woman, 
which  supervene  in  women  who  are  sanguine,  plethoric,  or  whose 
organs  are  all  surcharged  with  serosity  ;  which  are  accompanied 
2  Y 


386  DYSTOCIA. 

with  apoplectic  phenomena,  as  coma,  stertor,  or  complete  insensibi- 
lity during  the  intervals  of  the  paroxysms  ;  and  also  of  such  as  are 
only  the  symptoms  of  organic  disease  of  longer  or  shorter  stand- 
ing, seated  in  the  brain,  the  lungs,  the  heart,  or  any  other  important 
organ,  and  which  had  been  greatly  aggravated  by  pregnancy. 

894.  The  child  runs  scarcely  less  risk  than  the  mothe-;  in  the 
first  place,  it  often  dies  in  the  midst  of  the  extraordinary  motions 
that  mark  each  paroxysm  ;  and  then,  wherever  abortion  takes  place, 
its  life  cannot  be  preserved  ;  the  same  thing  often  takes  place  when 
premature  delivery  cannot  be  avoided  ;  and  even  in  forced  delivery 
also,  at  full  term,  the  foetus  is  often  lost ;  nevertheless  it  is  incorrect, 
with  some  authors,  to  state  that  the  loss  of  the  child  almost  always 
occurs  where  the  attack  of  puerperal  convulsions  is  somewhat 
severe.  Mauriceau,  De  la  Motte,  Levret,  Smellie,  Baudelocque, 
the  cases  gathered  or  collected  by  MM.  Bouteilloux,  J.  C.  Baude- 
locque, Madame  Lachapelle,  &c.  afford  proof  enough  of  the  con- 
trary. 

895.  Treatment.  A  disease  exhibiting  itself  under  forms  so 
diverse,  and  in  such  various  degrees,  cannot  be  cured  by  a  treat- 
ment that  is  alike  in  all  cases  :  it  is  therefore  not  astonishing  that 
we  have  so  many  boasted  remedies  for  it.  There  are  few  sub- 
stances among  the  anti-spasmodics,  the  sedatives,  the  narcotics,  the 
revulsives  and  the  anti-phlogistics,  which  have  not  had  their  vogue  ; 
but  as  there  is  always  too  much  disposition  to  generalise,  in, thera- 
peutics as  well  as  in  the  other  branches  of  medicine,  facts  have  not 
been  wanting  to  prove  that  such  or  such  an  article,  puffed  beyond 
measure  by  different  physicians,  is  more  injurious  than  useful  in 
eclaihpsia. 

Ether,  balm  water,  orange-flower  water,  and  mint  water,  mixed 
in  various  proportions  with  infusions  of  linden  flowers,  wild  poppies, 
orange  leaves,  lettuce  water,  &lc.  and  with  some  sedative  syrup,  are 
not  be  neglected  in  a  number  of  cases  where  the  convulsions  have 
more  analogy  with  hysteria  or  epilepsy  than  with  apoplexy,  especi- 
ally if  the  patient  is  nervous,  very  excitable,  or  lymphatic,  rather 
than  plethoric  and  sanguine. 

In  these  cases,  also,  the  syrup  of  clove  pinks,  of  white  poppies, 
of  diacodium,  pills  of  cynoglossus,  the  extract  and  tinctures  of 
opium,  may  be  usefully  given,  either  alone,  or  added  to  the  al)0ve 
mentioned  vehicles,  or  under  some  other  form,  and  combined  in 
8ome  other  manner. 

89G.  Rigidity,  scirrhous  induration  and  spasmodic  contraction  of 
the  03  uteri  being  sometimes  the  only,  or  at  least  the  principal  cause 
of  convulsions,  we  ought  not  to  omit  to  examine  it  carefully.     Pro- 


^  CONVULSIONS.  387 

▼i3edl1ialt*Tr'snou1J"seem  to  be  the  point  of  departure  for  the  dis- 
ease, we  should  apply  to  it  some  of  the  opiate  cerate,  from  which 
M.  Schweighaeuser  asserts  that  he  obtained  very  successful  results, 
or  what  is  better  still,  the  belladonna  ointment.  Were  it  really  too 
hard  to  be  overcome  by  the  efforts  of  the  womb,  I  do  not  see  that  it 
would  be  possible  to  dispense  with  incising  the  neck.  Upon  this  sub- 
ject the  fears  of  Madame  Lachapelle  are,  to  say  the  least,  exaggerated; 
for  I  have  not  learned  that  the  passage  of  the  head,  after  this  opera- 
tion, has  in  any  case  enlarged  the  wound,  so  as  to  perforate  the 
peritoneum.  However,  notwithstanding  what  has  been  said  by  M. 
Bodin,  it  is  a  resource  not  without  danger,  to  which  we  should  not 
under  any  pretext  resort,  except  in  case  of  indispensable  necessity. 

897.  Bleeding  has  always  enjoyed  much  favour  among  obstetric 
physicians  :  Mauriceau,  De  la  Motte,  Puzos,  &.c.  have  repeated  it 
six,  eight,  ten,  seventeen  and  evein  as  much  as  eighty-six  times  in  one 
pregnancy  in  the  same  woman  !  The  loss'of  blood  is  always  useful 
where  there  are  signs  of  congestion  about  the  head,  a  strong  pulse, 
or  any  signs  of  plethora.  The  blood  is  sometimes  drawn  from  a 
superficial  vein,  sometimes  by  means  of  leeches  or  cups,  and  at 
others  by  all  these  means  together.  Except  wliere  there  is  some 
particular  counter  irritation,  we  commonly  begin  with  a  general 
bleeding  of  six,  eight,  ten,  twelve,  or  even  fifteen  ounces, 
according  to  the  severity  of  the  disease,  and  the  constitution 
of  the  woman.  After  this  firsfc  venesection,  if  it  appears  to  produce 
some  amelioration,  it  is  repeated  a  second  time,  a  third,  or  even  a 
fourth,  at  intervals  more  or  less  considerable,  always  remembering 
that  in  this  way  the  strength  of  the  woman  is  rapidly  exhausted. 
When  the  general  bleeding  can  no  longer  be  repeated  with  the  hope 
of  obtaining  any  decided  advantage  from  it,  leeches  may  be  applied 
to  the  number  of  fifteen,  twenty,  thirty,  forty,  or  fifty,  behind  the 
ears,  or  on  the  neck,  or  even  in  the  neighbourhood  of  the  vulva, 
provided  there  should  be  any  appearances  of  irritation  or  evident 
congestion  in  the  pelvis.  Should  the  coma  be  very  profound,  and 
blood  not  to  be  got  except  in  very  small  quantity,  scarified  cups  on 
the  nape  of  the  neck,  or  on  the  mastoid  apophyses,  ought  also  to  be 
tried.  As  to  bleeding  from  the  temporal  artery,  or  even  from  the 
radial  artery,  proposed  by  some  persons,  I  do  not  think  that  it  de- 
serves any  preference  over  venesection  :  but  which  vein  ought  to  be 
opened  ? 

In  the  prevailing  theory  of  blood-letting  bleeding  in  the  foot  passes 
for  being  essentially  revulsive,  while  Weeding  from  the  neck  is  rather 
derivative,  and  that  from  the  arm  merely  depletive  ;  but  these  dis- 
tinctions are  scarcely  justified  by  practice  :  Baudelocque  has  seen 
bleeding  from  the  saphena  aggravate  the  affections  that  were  inva- 


4 


388  DYSTOCIA. 

riably  diminished  by  opening  a  vein  in  the  arm,  and  other  practi- 
tioners have  observed  the  inverse.  In  eclampsia  the  object  is  to 
disengorge  the  vascular  system,  and  when  bleeding  is  deemed  neces- 
sary, I  think  it  matters  little  whether  it  is  taken  from  one  vein  rather 
than  another.  If  the  cerebral  congestion  is  fixed  and  too  great, 
should  the  opening  of  the  jugulars  appear  to  be  indicated,  leeches  or 
cupping  might  be  regarded  as  preferable,  considering  that  bleeding 
in  the  neck  is  not  always  an  easy  nor  even  practicable  matter,  espe- 
cially in  a  person  labouring  under  convulsions. 

Another  reason  of  the  same  kind  will  long  continue  to  render 
bleeding  in  the  arm  much  more  general  than  bleeding  in  the  foot ; 
it  is  always,  or  almost  always  possible,  no  matter  how  agitated  the 
patient  may  be,  for  us  to  open  a  vein  in  the  bend  of  the  arm, 
whereas  as  much  cannot  be  said  as  to  the  veins  of  the  legs :  by 
bleeding  in  the  arm,  we  act  at  the  instant,  when  we  please,  and 
how  we  please,  and  we  take  much  or  little,  and  that  without  any 
difficulty.  By  bleeding  in  the  foot,  on  the  contrary,  various  prepa- 
rations are  required  ;  we  must  take  advantage  of  a  moment  of  calm, 
the  vein  is  often  found  to  be  too  small  or  too  deep-seated,  and  it 
frequently  happens  that  enough  blood  is  not  obtained. 

898.  Tepid  baths  allay  irritation,  whether  sympathetically  by 
their  soothing  action  on  the  skin,  whether  by  diminishing  the  ex- 
citing qualities  of  the  fluids  by  the  water  which  they  occasion  to 
pass  into  the  circulatory  system,  or  by  diminishing  the  force  of 
radiation  of  heat.  They  are  administered  with  success  where  the 
symptoms  of  apoplexy  do  not  predominate  ;  but  they  ought  not  to 
be  prescribed  until  a  bleeding  has  been  premised,  provided  the  state 
of  the  patient  is  such  as  to  admit  of  her  losing  blood  without  danger ; 
otherwise  it  might  fivour  the  affluxion  and  congestion  in  the  brain  ; 
they  should  be  rejected  in  cases  depending  on  flooding,  a  serous 
plethora,  and  where  there  are  any  threats  of  inertia ;  the  woman 
may  remain  immersed  in  a  ba^h  for  half  an  hour,  an  hour,  or  even 
longer,  according  to  the  relief  she  derives  from  it. 

899.  The  application  of  cold  water  to  the  belly,  according  to  the 
recommendation  of  Sigaud,  has  not  a  sufficient  number  of  facts  in 
its  favour  to  enable  us  to  recommend  it  in  this  form  as  a  general 
proposition.  Ablutions,  and  ice-water  to  the  head,  eitlier  used 
alone,  or  whilst  the  rest  of  the  body  is  plunged  into  a  hot  bath, 
which  Denman  and  most  of  the  English  authors,  as  well  as  M.  A. 
C.  Baudelocque,  Madame  Lachapelle,  &lc.  have  boasted  so  much 
of,  appear  as  if  they  might  indeed  be  usefully  combined  with  the 
other  rational  means  wiiere  there  is  reason  to  fear  a  lively  reaction 
in  the  brain ;  nevertheless  their  employment  seems  to  me  to  require 
a  great  deal  of  prudence  and  circumspection. 


CONVULSIONS.  389 

900.  Oily  or  irritating  injections  of  all  sorts  are  frequently  used 
in  England,  and  not  without  success.  In  France,  they  prefer  ex- 
ternal revulsives,  sinapisms  or  sinapised  cataplasms,  to  the  feet,  legs, 
or  thighs,  a  large  blister  on  the  back  of  the  neck,  and  dry  frictions 
along  the  spine,  and  on  the  limbs.  Madame  Lachapelle,  who  does 
not  place  much  confidence  in  them,  and  is  even  afraid  of  them  where 
there  is  a  threatening  of  inflammation  in  any  one  of  the  organs,  also 
rejects  the  employment  of  digitalis  and  camphor,  to  which  Hamilton 
attributes  very  great  virtue,  and  blames  the  conduct  of  our  trans- 
marine neighbours,  which  consists  in  a  recourse  to  purgatives  and 
even  to  emetics,  after  bleeding.  Without  charging  myself  with  tire 
defence  of  the  accoucheurs  of  Great  Britain,  I  cannot,  however, 
omit  to  observe,  that  out  of  twenty-two  women  treated  by  bleed- 
ing, calomel  in  purging  doses,  neutral  salts  given  by  the  mouth  or 
by  injection,  and  lotions  made  with  liquid  acetate  of  ammonia  or 
spirit  of  rosemary,  to  the  head,  Merriman  lost  only  six,  while  in 
spite  of  the  energy  of  the  practice  employed  at  the  Maternitd,  they 
have  almost  as  many  deaths  as  cures  in  that  institution. 

The  digitalis  purpurea,  which  is  recommended  by  Hamilton^  may 
be  tried  in  convulsions  preceded  by  cedema  of  the  limbs.  The  seton 
in  the  back  of  the  neck,  as  advised  by  M.  C.  Baudelocque,  ought 
not  to  be  employed  until  all  other  remedies  have  been  found  insufli- 
cient ;  moxas  and  scarified  cups  are  not  likely  to  be  at  all  more  suc- 
cessful than  leeches  and  the  common  revulsives. 

901.  To  conclude,  bleeding  from  the  arm,  the  foot,  or  the  jugular 
vein,  is  useful,  and  oftentimes  even  indispensable,  in  the  convulsions 
of  pregnant  and  puerperal  women,  whether  of  a  slight  or  severe 
character,  where  the  patient  is  young,  strong,  and  of  a  good  consti- 
tution, and  not  exhausted  by  preceding  hemorrhages.  Local  blood- 
letting is  the  only  kind  we  can  resort  to  where  the  convulsions  super- 
vene upon  a  flooding,  or  in  persons  who  have  been  debilitated  in  any 
way,  or  those  of  a  lymphatic  constitution,  &c.  In  that  case,  if  they 
occur  after  delivery,  and  the  lochiaj  have  ceased  to  flow,  leeches  may 
be  applied  to  the  labia  or  to  the  groin,  as  recommended  by  M.  C. 
Baudelocque,  otherwise  they  should  be  applied  to  the  mastoid  apo- 
physes, according  to  the  counsel  of  Chaussier. 

When  the  vascular  system  has  been  depleted,  if  the  state  of  the 
patient  admits  of  it,  a  tepid  bath  should  be  prescribed ;  if  irritation 
or  spasmodic  contraction  of  the  os  uteri  appears  to  be  the  cause  of 
the  phenomena,  some  opiate  cerate,  or  belladonna  ointment  should 
be  applied  to  it.  After  a  flooding,  or  a  painful  or  fatiguing  labour 
or  delivery  of  the  placenta,  some  analeptic  broths  and  a  few  spoon- 
fuls of  sound  wine  will  occasionally  be  found  the  best  remedies  that 


390  DYSTOCIA. 

can  be  made  use  of.  Where  the  woman  is  delicate  and  nervons, 
we  have  recourse  to  sedative  infusions  and  waters,  narcotic  prepa- 
rations, &.C.  Sinapisms,  blisters,  scarifications  and  other  revulsives 
are,  in  severe  cases,  particularly  useful  as  accessory  in  effect  to 
blood-letting,  or  as  supplementary  to  those  evacuations,  where  they 
are  themselves  inadmissible.  Finally,  should  there  be  manifest 
symptoms  of  disordered  stomach  or  bowels,  without  any  of  the  signs 
of  inflammatory  irritation,  I  do  not  perceive  that  there  would  be  any 
temerity  in  promoting  either  the  vomiting  or  the  alvine  evacuations 
by  means  of  gentle  emetics  and  purgatives :  but,  during  the  labour, 
the  best  remedy  beyond  dispute  is  the  delivery  of  the  child. 

902.  Where  the  disease  comes  on  before  the  end  of  the  sixth 
month,  we  ought  to  do  every  thing  in  our  power  to  succeed  without 
soliciting  the  expulsion  of  the  foetus;  its  viability  being  at  a  later 
period  possible,  there  is  no  longer  any  need  for  so  many  precautions 
on  this  head. 

To  admit  of  the  child  being  delivered,  either  with  the  hand  or 
with  the  forceps,  it  is  necessary  that  the  dilatation  of  the  cervix 
should  be  very  advanced,  or  at  least  that  the  'os  uteri  should  be 
sofl  enough  to  admit  of  the  womb  being  entered  without  the  em- 
ployment of  any  great  degree  of  force.  However,  if  a  trial  have 
been  ineffectually  made  of  ointments,  injections,  and  baths';  if  the 
woman  or  the  child  were  in  imminent  danger,  and  a  forced  delivery 
the  only  means  of  safety  ;  and  in  a  case  where  the  os  uteri  should  be 
thin,  but  hard  and  undilatable,  and  obstinately  resist  the  contrac- 
tions of  the  womb,  there  ought  to  be  no  hesitation  in  following  the 
counsel  of  M.  Bodin,  to  make  one  or  more  incisions  into  its  con- 
cave edge,  or  in  resorting  to  what  has  been  called  since  the  time  of 
Simson  and  Lauvergeat  the  vaginal-cesarian  operation. 

§.  III.  Dystocia  caused  by  the  premature  descent  of  the  umbili- 
cal cord. 

903.  Although  not  a  rare  occurrence,  procidence  of  the  cord  is 
not  very  frequently  met  with,  for  it  was  observed  to  happen  forty-one 
times  in  15,652  labours,  at  the  Maternite  at  Paris  ;  its  being  more 
frequently  met  with  in  private  practice  seems  to  depend  upon  the 
hasty  maneuvres  of  the  persons  who  assist  the  lying-in  woman, 
rather  than  any  other  cause  :  Black  has  even  asserted,  but  it  is  evi- 
dent erroneously,  that  the  descent  of  the  cord  is  always  the  effect  of 
attempts  to  hasten  the  delivery.  A  woman  was  brought  to  my 
amphitheatre  while  I  was  delivering  a  lecture  ;  she  was  compelled 
to  wait  half  an  hour  at  the  porter's  lodge  ;  no  one  examined  her, 
and  when  she  was  brought  up  to  the  ward,  the  cord  formed  a  loop 


PROLAPSED  CORD.  391 

of  several  inches  hanging  out  of  the  vagina,  although  the  os  uteri 
was  but  very  little  dilated.  Moreovei-,  there  are  but  few  accouch- 
eurs in  large  practice  who  have  not  had  several  opportunities  of 
observing  the  same  thing. 

904.  The  causes  of  this  accident  may  be  referred,  1.  To  the  ex- 
cessive quantity  of  the  liquor  amnii  ;  2.  To  too  great  a  length  of 
the  cord ;  3.  To  the  too  sudden  escape  of  the  waters  upon  the 
rupture  of  the  membranes. 

905.  The  procidence  of  the  cord  has  always  been  noted  by 
authors  as  a  dangerous  accident.  Not  because  it  renders  the 
labour  more  difficult,  or  causes  the  woman  to  run  any  greater  risk, 
but  because  the  fatus  is  thereby  exposed  to  the  hazard  of  dying 
before  it  can  be  delivered.  Its  death  in  this  case  is  indisputably 
produced  by  the  cessation  of  the  circulation  of  the  blood  through 
the  cord,  and  all  the  reasons  collected  in  the  memoir  by  Thouret 
are  insufficient  to  weaken  this  proposition  ;  but  the  obstacle  to  the 
circulation  has  not  been  understood  in  the  same  way  by  all  ac- 
coucheurs. 

Until  the  time  of  De  la  Motte,  who  did  justice  to  this  notion,  it 
had  been  generally  supposed  that  the  blood,  from  becoming  chilled 
by  the  external  temperature,  coagulated,  or  became  concrete  in  the 
loop  of  the  cord  hanging  out  of  the  vulva. 

At  present,  the  accidents  attending  it  are  attributed  to  compres- 
sion alone.  In  fact,  as  soon  as  the  waters  are  all  gone  off,  if  the 
cord  descends  before  the  head,  the  breech,  &c.  its  vessels  are 
almost  necessarily  flattened  during  the  expulsive  efforts.  Neverthe- 
less, if  the  pelvis  be  very  large  and  the  foetus  small,  and  the  cord  is 
placed  near  one  of  the  sacro-iliac  notches  while  the  forehead  or  the 
occiput  is  towards  the  opposite  one,  the  compression  of  its  vessels 
may  be  so  slight  as  not  to  prevent  the  blood  from  pursuing  its  route. 

906.  Death  takes  place  from  an  excess  of  blood,  or  apoplexy,  if 
M.  Chambon  is  to  be  believed  ;  from  anemia  or  syncope,  according 
to  Baudelocque,  MM.  Capuron,  Deneux,  &c.;  from  asphyxia,  or 
want  of  oxygenation  of  the  blood,  according  to  Muller.  But  neither 
of  these  three  hypotheses  is  correct.  It  is  impossible  to  maintain 
with  Freteaux,  that  the  vein  is  less  compressed  than  the  arteries,  or 
with  others,  that  just  the  contrary  happens.  All  three  of  the  ves- 
sels are  compressed  alike,  and  the  death  of  the  foetus  is  to  be  ex- 
plained not  upon  the  quantity,  but  the  quality  of  the  blood  it  re- 
ceives. 

907.  Prognosis.  If  the  cord  is  cold,  without  pulsation,  shrunk, 
and  greenish,  the  death  of  the  child  is  indubitable  ;  if  the  labour  is 
still  far  from  its  termination,  the  head  strongly  engaged,  and  it  is 


392  DYSTOCIA. 

diffirult  to  alter  its  position,  the  prognosis  will  be  very  unfavourable. 
On  the  contrary,  if  the  pulsations  are  kept  up  with  some  degree  of 
force,  and  the  labour  goes  on  rapidly,  even  although  the  cord  be 
lank  and  shrunken,  its  premature  escape  may  be  followed  by  no  un- 
pleasant effect. 

908.  Treatment.  There  are  different  ways  of  remedying  this  pro- 
cidence.  If  the  child  presents  transversely,  by  the  shoulder,  or  by 
the  hip,  and  the  os  uteri  be  not  sufficiently  dilated  to  admit  of  an  at- 
tempt to  turn,  we  must  try  to  return  the  loop  into  the  womb ;  where 
the  labour  is  pretty  well  advanced,  we  have  to  seek  for  the  feet,  and 
it  would  even  be  dangerous,  whenever  the  pulsations  of  the  cord  are 
found  to  grow  sensibly  weaker,  to  wait  for  a  complete  dilatation 
before  we  act. 

Where  the  pelvic  extremity  of  the  fcetus  presents,  as  soon  as  the 
contractions  become  sufficiently  strong,  we  have  to  favour  their 
effect  by  pulling  downwards  in  a  proper  way  upon  the  lower 
extremities.  But  it  is,  particularly,  where  it  escapes  before  the  head 
that  the  cord  requires  prompt  assistance. 

In  such  cases  the  ancients  confined  themselves  merely  to  pushing 
it  up  again,  and  keeping  it  wrapped  up  in  a  linen  rag  in  the  vagina  ; 
modern  surgeons  make  use  merely  of  their  fingers,  or  of  a  piece  of 
whalebone  surmounted  with  a  sponge  or  with  a  ring.  Ducamp  has 
recommended  a  species  of  pincers,  enclosed  in  a  canula,  in  most 
respects  similar  to  the  porte-nceud  of  Dessault ;  M.  Dudan  thinks 
we  should  be  satisfied  with  a  gum  elastic  catheter.  No.  9,  furnished 
with  its  wire,  which  serves  to  fix  the  end  of  a  ribbon  passed  through 
one  of  the  eyes  of  the  instrument.  With  this  ribbon  M.  Dudan  sus- 
tains the  cord  at  the  end  of  the  catheter  without  compressing  it,  and 
returns  it  into  the  cavity  of  the  womb,  where  he  afterwards  leaves  it, 
first  withdrawing  the  wire,  and  then  the  catheter  itself.  The  canula 
a  chamiere,  proposed  by  Wel'emborg,  would  in  fact  be  more  dange- 
rous than  useful,  and  I  doubt  whether  any  accoucheur  will  be  ever 
tempted  to  make  use  of  it.  It  has  also  been  advised  to  introduce 
and  fix  graduated  compresses  or  bits  of  sponge  betwixt  the  head  of 
the  foetus  and  the  parts  of  the  mother.  Finally,  Mr  Croft  finds  it 
more  expeditious  and  more  safe  to  carry  the  whole  hand  into  the 
womb,  so  as  to  hook  the  loop  of  the  cord  over  one  of  the  limbs  of 
the  child. 

Doubtless,  most  of  these  means  might  succeed  ;  but  there  is  not 
one  of  them  that  ought  to  be  adopted  exclusively;  for  the  conduct  to 
be  pursued  will  necessarily  vary  according  to  the  state  of  the  cir- 
cumstances. 

909.  When  the  child  is  dead,  the  presence  of  the  cord  requires  no 


PROLAPSED  CORD.  393 

particular  maneuvre.  If  it  be  living,  the  head  may  be,  1,  Upon  the 
point  of  clearing  the  inferior  strait ;  and  in  that  case  we  need  only 
urge  the  woman  to  bear  down  upon  the  pains  as  hard  as  she  can  ; 

2.  In  the  excavation,  and  the  labour  may  go  on  but  slowly  ;  the  re- 
duction is  here  impossible,  and  if,  after  trying  it,  we  find  the  pulsa- 
tions of  the' cord  diminishing,  we  must  hasten  to  apply  the  forceps  ; 

3.  Lastly,  scarcely  engaged ;  here  we  take  hold  of  the  cord,  and  roll 
it  up  into  a  kind  of  ball  which  we  endeavour  to  return  by  pushing 
it  up  by  the  side  of,  or  even  above  the  head,  if  possible,  and  if  there 
is  any  tendency  for  it  to  fall  down  again,  it  should  be  kept  there  until 
the  contractions  have  firmly  fixed  the  cranium  in  the  strait.  Pro- 
vided the  introduction  of  the  fingers  were  found  too  difficult,  or  in- 
sufficient, some  mechanical  means  might  be  tried  ;  such  as  the 
instrument  of  Ducarap,  or  Dudan's,  or  what  is  still  better,  the  porte- 
cordon  in  the  shape  of  a  fork,  invented  by  M.  Guillon.  Rather  than 
proceed  to  turning,  recourse  ought  to  be  had  even  to  the  method 
recommended  by  Dr  Croft. 

On  this  subject  Madame  Lachapelle,  as  well  as  many  other  mo- 
derns, says  that  the  precept  of  the  English  surgeon  ought  not  to  be 
followed,  inasmuch  as,  where  the  hand  is  introduced,  it  would  be 
quite  as  speedy  to  draw  down  the  feet.  For  my  part,  I  am  not  of 
that  way  of  thinking;  the  life  of  the  child  is  too  much  endangered 
in  forced  delivery  by  the  feet,  for  us  not  to  prefer  delivery  by  the 
head  whenever  it  is  possible. 

When  compelled  to  extract  the  foetus  by  the  hand  or  by  the  for- 
ceps, it  is  important  to  conform  to  the  precept  of  Boer,  which  is, 
that  previously  to  acting  either  upon  the  feet  or  the  head,  we  ought 
not  the  less  to  endeavour  to  return  the  cord,  which,  without  such 
precaution,  could  scarcely  fail  to  be  very  much  compressed,  cither 
by  the  hand  of  the  accoucheur,  or  by  the  hips,  the  shoulders,  or 
some  other  solid  part  of  the  child. 

§.  IV.  Dystocia  from  excessive  length  or  shortness  of  the  umbili- 
cal cord. 

910.  Shortness.  Until  the  time  of  Baudelocque  it  was  supposed 
that  the  delivery  of  the  foetus  might  be  prevented,  or  at  least  consi- 
derably retarded  by  a  very  short  cord.  When  the  placenta  is 
attached  to  the  fundus  of  the  womb,  if  the  cord  is  less  than  six  or 
eight  inches  in  length,  says  De  la  Motte,  the  head,  which  is  forced 
towards  the  inferior  strait  during  the  contractions,  is  found  to  rise 
upwards  again  during  the  intervals  between  the  pains  ;  the  occiput 
is  seen  to  engage  in  the  vulva,  to  be  on  the  point  of  clearing  the 
strait  at  every  effort  made  by  the  woman,  and  then,  as  soon  as  the 
2Z 


394  DYSTOCIA. 

pain  is  off,  it  re-entei-s  the  passage  ;  and  this  continues  for  several 
hours.  Mf 

The  circumstance  really  takes  place,  but  is  altogether  independent 
of  the  umbilical  cord  ;  it  is  chiefly  to  be  met  with  in  young  women 
who  are  strong  and  robust,  and  at  their  first  confinement.  It  de- 
pends upon  the  elasticity  of  the  perineum  :  this  flooring  of  the  pelvis 
gives  way  while  the  womb,  assisted  by  the  abdominal  muscles,  urges 
the  head  onwards  and  makes  it  project  from  the  parts  ;  but  as  soon 
as  the  contraction  ceases,  its  natural  resistance  returns  the  vertex 
into  the  interior  of  the  pelvis. 

However,  it  would  be  incorrect  to  assert,  as  Baudelocque  does, 
that  a  cord's  being  too  short  cannot  in  any  case  interfere  injuriously 
with  delivery  ;  in  such  a  case  the  placenta  is  liable  to  be  prematurely 
detached,  which  might  facilitate  the  occurrence  of  inversion  of  the 
womb,  give  rise  to  hemorrhagy,  and  bring  the  child's  life  into  dan- 
ger, should  the  labour  be  prolonged  ;  the  strain  arising  from  it  might 
weaken,  or  even  arrest,  or  at  least  disturb  the  contractions  of  the 
womb,  and  suspend  the  labour  ;  but  in  no  case  can  the  mere  short- 
ness of  the  cord  mechanically  hinder  the  expulsion  of  the  child. 

911.  Excessive  length.  When  the  cord  is,  on  the  contrary,  too 
long,  it  generally  has  a  strong  tendency  to  procidence,  and  particu- 
larly to  the  formation  of  one  or  more  loops  around  the  limbs  or 
body  of  the  foetus.  These  turns  are  frequently  met  with  in  prac- 
tice, and  oftener  round  the  neck  than  any  where  else ;  where  there 
are  many  of  them,  that  portion  of  the  cord  that  remains  free  may  be 
really  too  short,  whence  the  same  accidents^  as  under  the  former 
head  might  be  feared.  It  has  also  been  thought  that  they  might 
obstruct  the  passage  of  the  blood  in  the  jugular  veins,  and  act  like 
ligatures,  so  as  to  produce  a  state  of  asphyxia.  I  have  seen  many 
children  born  with  turns  of  the  cor4  about  the  neck,  and  it  has  never 
seemed  to  me  to  be  productive  of  danger  in  any  case.  Besides,  in 
strangulation,  death  is  produced  by  the  stoppage  of  respiration,  and 
death  cannot  take  place  in  that  way  in  the  foetus :  again,  1  do  not 
see  how  the  cord  can  be  drawn  so  tightly  as  to  obliterate  the  inter- 
nal jugulars  or  the  carotids ;  therefore,  at  most,  only  the  umbilical 
vessels  are  liable  to  be  interrupted.  It  would  appear,  however,  that 
these  turns  of  the  cord  may  exist  for  several  months  before  the  pe- 
riod of  delivery,  and  thus  give  rise  to  some  very  curious  anomalies. 
A  fact  lately  observed  by  M.  Monod,  a  resident  pupil  at  the  Mater- 
nite,  proves  that  they  may,  like  a  branch  of  ivy  round  a  tree,  leave 
very  deep  grooves,  and  produce  strangulations,  &c.  from  which 
even  the  bones  do  not  wholly  escape.  Moreover,  it  is  fortunate 
that  these  causes  of  dystocia  cither  do  not  exist  at  all,  or  but  very 


THE  CORD,  ANEURISM,  ASTHMA.  395 

rarely,  for  it  is  impossible  to  discover  them  until  the  head  has 
passed  the  inferior  strait ;  except  in  certain  cases  of  breech  presen- 
tation, in  which  the  cord  may  be  felt  tightly  stretched,  either  betwixt 
the  thighs,  around  one  of  the  limbs,  or  merely  up  along  the  abdo- 
men, we  can  suspect  the  existence  of  these  turns  only  upon  conjec- 
tures that  are  too  uncertain  and  vague  to  deserve  the  least  confidence. 
If,  however,  it  should  be  ascertained  that  the  cord  is  too  short,  it 
ought  to  be  immediately  cut,  provided  there  should  be  any  danger 
to  the  child,  and  the  labour  still  far  from  its  terminatjpn ;  care  should 
be  then  taken  to  deliver  the  woman  as  early  as  possible,  either  by 
the  hand  or  with  the  forceps.  When  it  is  not  discovered  until  the 
escape  of  the  head,  it  is  in  general  easily  to  be  remedied  :  if  the 
turn  be  a  very  loose  one,  and  the  cord  very  long,  the  birth  of  the  child 
is  most  generally  not  at  all  obstructed  by  it,  and  nothing  need  be  done ; 
in  the  contrary  case,  we  must  either  disengage  or  cut  the  loop,  so 
that  the  respiration  may  not  be  long  in  becoming  established*. 

§.  V.  Aneurismal  dystocia. 

912.  An  aneurism  within  the  splanchnic  cavities,  or  even  in  one 
of  the  great  external  arteries,  is  always  a  serious  disease  ;  but  it  is  yet 
rendered  still  more  dangerous  by  the  efforts  of  labour.  The  con- 
tractions of  the  muscles  and  the  repulsion  of  the  blood  consequent 
thereto  might  readily  occasion  the  rupture  of  a  sanguine  tumour,  if 
haste  were  not  made  in  emptying  the  womb.  In  such  cases,  there- 
fore, the  patient  should  be  adviseS  to  assist  her  pains  as  little  as  pos- 
sible, and  as  soon  as  the  orifice  is  sufficiently  dilated  or  dilatable, 
the  child  should  be  extracted  either  with  the  hand  or  the  forceps. 

§.  VI.  Dystocia  from  asthma,  hydrothorax,  gibbosity,  dropsy,  &c. 

913.  All  diseases  that  render  the  respiration  difficult,  may  make 
it  necessary  for  us  not  to  trust  the. labour  to  the  mere  resources 
of  the  organism.  It  is  well  known  that  asthmatic  persons  are  soon 
threatened  with  suffiacation  when  under  any  state  of  violent  exer- 
tion ;  and  that  the  same  holds  good  of  those  who  are  labouring  under 
some  effiision  in  the  chest,  or  in  whom  the  free  expansion  of  the 
chest  is  restrained  by  a  deviation  of  the  spine,  &:.c.  All  wise  prac- 
titioners therefore  have  recommended  that  in  these  circumstances 
the  efforts  of  the  woman  should  be  controlled,  and  that  she  should 
be  artificially  delivered  as  soon  as  the  state  of  the  parts  admits  of 
the  child's  feet  being  brought  down  safely. 

*  Dr  Smith,  who  relates  a  case  of  inversion  of  the  womb,  produced  by  (he 
shortness  of  the  cord,  recommends,  with  reason,  that  we  should  draw  down  a 
portion  of  that  which  is  connected  with  the  placenta,  and  then  slip  the  noose 
over  the  shoulders,  and  not  over  the  head  of  the  child. 


396  DYSTOCIA. 

914.  The  same  precept  has  been  given  where  the  labour  is  com- 
plicated by  the  presence  of  some  large  tumour  in  the  abdomen,  or 
with  a  dropsy  in  that  cavity ;  and  that,  because  here,  as  in  the  pre- 
ceding cases,  the  efforts  of  the  womb  might  give  rise  to  a  fear  of 
asphyxia,  or  at  least  might  be  followed  by  a  dangerous  collapse. 

916.  However,  I  ought  to  remark  that  many  dropsical  women  go 
through  their  labours  almost  as  easily  as  those  who  are  in  the  enjoy- ' 
ment  of  perfect  health.  I  saw  at  the  hospital  de  Perfectionnement, 
in  1824,  a  woman  labouring  under  ascites  who  had  been  tapped 
thirty-six  times,  and  who  was,  notwithstanding,  delivered  very  natu- 
rally after  a  labour  of  a  few  hours  duration.  Another  one  came 
to  the  same  establishment  in  1826,  who  had  been  dropsical  for  four 
years,  and  whose  labour  lasted  only  two  hours,  although  her  abdo- 
men was  enormously  large,  and  although  from  ten  to  fifteen  litres 
of  fluid  had  been  several  times  drawn  off  from  the  belly  by  tapping. 

Nevertheless,  as  the  abdominal  muscles  are  generally  very  much 
weakened,  and  separated,  in  ascites,  by  a  thick  stratum  of  flqid,  their 
mediate  action  can  be  possessed  of  but  little  energy  in  the  expulsive 
part  of  labour. 

§.  VII.  Hernial  dystocia. 

916.  When  the  hernia,  of  whatever  species  it  may  be,  is  reducible, 
it  should  be  returned  to  its  proper  situation  before  the  pains  become 
very  strong,  and  then  during  each  contraction  its  escape  is  to  be 
prevented  by  holding  the  thumb,  a  compress,  or  the  hand,  upon  the 
opening  through  which  it  passes  outwards.  This  maneuvre  is  to 
be  attended  to  by  the  accoucheur,  or  at  least  by  an  assistant  fit 
to  be  trusted,  and  not  by  the  woman  herself.  When  it  is  an  old 
and  irreducible  one,  we  must  be  content  to  support  it  exactly, 
so  as  to  prevent  it  from  becoming  strangulated,  or  receiving  an  ad- 
dition of  new  portions  of  viscera  to  those  already  contained  wjthin 
the  tumour.  Beyond  this,  the  labour  requires  no  particular  assis- 
tance, and  we  should  confine  ourselves  merely  to  moderate  the  dis- 
position of  the  woman  to  improve  her  pains  by  bearing  down ;  neve- 
thelcss,  should  the  violence  of  the  efforts  be  such  that  nothing  could 
prevent  the  descent,  or  if  there  should  be  strangulation  and  the 
labour  far  advanced,  the  child  should  be  extracted  with  all  suitable 
precautions  as  soon  as  the  dilatation  of  the  os  uteri  admits  of  it. 

§.  VIII.  Dystocia  from  syncope. 

917.  Some  women  arc  so  delicate,  or  so  irritable  and  nervous, 
tliat  they  fall  into  syncope  from  the  least  pains ;  in  otiier  cases  the 
syncope  and  fainting  arc  due  to  the  extreme  distention  of  the  uterus, 
to  ilie  force  of  the  contractions,  to  inanition,  to  an  attack  of  hemor- 


SYNCOPE.  397 

rhage,  &c.  In  a  lady  who  was  pregnant  with  twins,  M.  Desor- 
meaux  found  them  to  last  throughout  the  whole  interval  of  the  con- 
tractions, and  the  woman  only  came  out  of  them  while  the  womb 
was  reacting  with  violence  upon  its  contents.  Antispasmodics  and 
opiates,  either  applied  to  the  os  uteri  or  taken  internally  by  the 
mouth  or  anus,  cordial  tinctures  and  other  such  articles,  a  few 
spoonfuls  of  sound  wine,  or  of  broth,  light  food,  &.c.  may  be  tried 
in  succession  or  by  turns ;  but,  says  M.  Desormeaux,  provided  the 
life  of  the  woman  be  threatened,  we  cannot  wait  for  the  effects  of 
remedies,  no  matter  how  well  chosen  they  may  be :  under  such  cir- 
cumstances, to  temporize  would  be  a  serious  fault ;  we  should  ter- 
minate the  labour  as  soon  as  possible,  in  order  to  prevent  a  fatal 
exhaustion.  ' 

918.  It  is  uncommon  for  weakness,  properly  so  called,  to  render 
a  labour  difficult ;  every  day,  valetudinary  and  phthisical  women  are 
met  with  who  can  scarcely  stand,  and  yet  bear  their  children  without 
difficulty.  Others  are  not  prevented  from  being  delivered  naturally  by 
a  state  of  lethargy,  of  asphyxia,  &.C.,  and  on  more  than  one  occasion 
the  womb  has  been  found  to  retain  enough  contractility  in  dying  wo- 
men, or  in  those  who  had  just  expired,  to  effect  the  expulsion  of  the 
ovum.  There  are  two  principal  reasons  why  our  succours  are  most 
commonly  unnecessary  in  these  cases :  1 .  Although  the  muscles  and 
the  uterus  have  to  a  great  degree  lost  their  contractile  faculty,  the  soft 
parts  of  the  pelvis  and  the  perineum  also  offer  much  less  resistance; 
2.  The  feeblest  women,  even  those  who  seem  to  be  upon  the  point 
of  expiring,  ordinarily  recover  an  amount  of  courage  and  energy 
that  forms  a  striking  contrast  to  their  extreme  exhaustion, 

919.  Notwithstanding,  it  is  not  a  rare  thing  to  see  these  mo- 
,  mentary  efforts  followed  by  an  oppression  and  sinking,  from  which 

the  women  recover  only  after  having  run  the  greatest  risks  j  many 
of  them  even  are  scarcely  delivered  till  they  fall  into  a  morbid  col- 
lapse, or  sink  gradually  into  death  after  a  few  hours,  as  if,  in  acting 
with  some  degree  of  violence,  nature's  only  object  had  been  to  ter- 
minate the  great  act  of  reproduction  happily,  at  the  risk  of  exhaust-^ 
ing  in  an  instant  the  small  remaining  strength  still  belonging  to  the 
organs!  A  young  woman  six  months  gone  with  child,  who  had 
been  labouring  for  thirteen  days  with  an  attack  of  phlebitis,  and  who 
was  in  a  decidedly  adynamic  state,  was  seized  with  the  pains  of 
abortion  at  four  o'clock  in  the  morning  ;  at  ten  o'clock  the  os  uteri 
was  soft,  and  of  the  size  of  a  three  livres  piece  ;  at  each  contraction 
her  cries,  anguish,  and  agitation  restored  an  appearance  of  strength, 
the  existence  of  which  was  not  suspected  a  kw  hours  before  :  the 
poor  woman  was  urged  to  redouble  her  courage,  and  make  the 


398  DYSTOCIA. 

Utmost  of  her  efforts ;  in  fact  the  child  was  delivered  at  about  eleven 
o'clock,  but  in  an  hour  afterwards  she  was  no  more. 

Consequently,  as  soon  as  the  os  uteri  is  sufficiently  dilated,  where- 
ever  there  is  reason  to  fear  too  great  a  degree  of  exhaustion,  pru- 
dence requires  us  to  have  recourse  to  a  forced  delivery.  The  for- 
ceps should  be  preferred  in  such  cases,  provided  turning  be  not 
absolutely  indicated,  inasmuch  as  it  is  less  fatiguing  for  the  woman. 


SECTION  2. 

Essential  Dystocia. 

Labour  is  essentially  difficult  where  the  passage  of  the  foetus  re- 
quires the  interference  of  art,  from  its  being  rendered  impossible, 
or  greatly  obstructed  from  some  mechanical  obstacle.  Of  these 
obstacles,  some  depend  upon  the  woman  ;  others,'  oh  the  contrary, 
depend  upon  the  fcEtus  itself. 

.    §.  I.  Dystocia  occasioned  by  the  state  of  the  female  organs. 

The  difficulties  that  arise  in  the  organs  of  the  female  are  sometimes 
referred  to  the  soft  parts,  and  at  others  to  the  hard  parts  of  her  struc- 
ture. The  former  alone  will  occupy  our  attention  here,  for  as  much 
as  the  latter  were  treated  of  in  the  section  on  deformed  pelvis. 

920.  Various  tumours  have  been  observed  in  the  pelvic  excava- 
tion, and  on  more  than  one  occasion,  great  difficulty  has  arisen  from 
them  in  regard  to  the  birth  of  the  child. 

They  are  pretty  frequently  found  to  occur  in  the  perineum,  or  in 
the  rectO'vaginal  septum  ;  being  variable  as  to  size,  consistence, 
nature,  &c.  they  are  far  from  always  requiring  the  same  kind  of 
treatraipnt ;  when  not  very  large  or  capable  of  being  flattened  by 
pressure,  if  other  circumstances  are  favourable,  they  do  not  always 
prevent  the  spontaneous  delivery  of  the  child  ;  scirrhous  or  fibrous 
masses  connected  with  tlie  ovary,  the  intestines  or  epiploon,  when 
sufficiently  movable  to  sink  down  and  lodge  betwixt  the  uterus  and 
sides  of  the  pelvis,  present  a  peculiar  indication  ;  they  require  to  be 
displaced  and  carried  above  the  superior  strait ;  for  this  purpose, 
the  woman  must  be  placed  upon  her  back  or  side,  in  such  a  way  that 
the  pelvis  may  be  higher  than  the  breast,  and  all  the  muscles  in  a 
state  of  relaxation  ;  then,  by  means  of  the  hand  or  fingers,  we  at- 
tempt to  push  the  tumour  out  of  the  passage  ;  finally,  when  all  at- 
tempts at  reduction  have  proved  to  be  fruitless,  it  may  become  indis- 
pensably necessary  to  extract  the  tumour  by  making  incisions 
through  the  vagina  or  rectum,  or  even  to  have  recourse  to  the 
cesarean  operation. 


TUMOURS,  URINARY  CALCULI.  399 

92 1 .  Sarcomatous^  scrofulous,  fibrous  or  other  tumours  that  are 
situated  in  the  cellular  tissue  of  the  pelvis,  and  that  cannot  be  dis- 
placed, are  much  more  dangerous  than  the  foregoing  ones ;  by 
resisting  the  head  of  the  child,  they  expose  the  womb  and  other 
organs  contained  within  the  excavation  to  contusions,  perforations 
and  lacerations  that  it  is  not  always  an  easy  matter  to  prevent; 
they  also  induce  inertia  and  exhaustion,  and  pretty  frequently  excit* 
hemorrhagies,  convulsions,  or  various  kinds  of  inflammations. 

922.  Those  of  the  recto-vaginal-septum  are,  most  generally,  sim- 
ple encysted  tumours  ;  this  at  least  seems  to  result  from  the  obser- 
vations of  Plenck,  of  M.  Pelletan,  and  a  case  recently  noticed  by 
M.  Roux  at  La  Charite  at  Paris.  The  woman  has  sometimes  suc- 
ceeded in  expelling  them,  either  through  the  anus  or  through  a 
laceration  in  the  perineum.  In  some  cases  they  have  been  ruptured 
by  the  muscular  efforts,  and  that  without  any  ill  consequences,  when 
the  fluid  they  contained  was  permitted  to  escape  into  the  rectum, 
the  vagina,  or  even  to  be  efiused  in  the  surrounding  cellular  tissue. 
But  they  may  also  end  in  abscess,  gangrene,  or  a  mortal  peritonitis, 
if  the  laceration  extends  into  the  peritoneum.  It  is,  therefore,  most 
prudent  to  empty  them  or  extract  them  as  soon  as  they  are  ascer- 
tained to  be  capable  of  hindering  the  escape  of  the  foetus,  or  ren- 
dering it  dangerous.  In  such  cases,  it  is  not  always  an  easy  matter 
to  distinguish  an  hydatid  or  encysted  tumour  from  such  as  are  solid  ; 
but,  as  has  been  pointed  out  by  M.  Desormeaux,  a  puncture  with  a 
small  trocar  will  suffice  to  remove  all  doubts  upon  the  subject. 

923.  Calculi  in  the  bladder.  It  is  evident  that  a  large  stone 
might,  during  labour,  become  situated  directly  behind  the  pubis,  so 
as  to  shorten  the  antero-posterior  diameter  of  the  pelvis.  But  a 
stone  being  violently  pressed  from  above  downwards,  by  the  child's 
head,  would  almost  necessarily  give  rise  to  contMion  or  laceration 
of  the  bladder  or  of  the  recto-vaginal  septum,  as  well  as  the  pain 
that  would  ensue  thereupon.  It  would  be  easy,  at  the  commence- 
ment of  labour,  to  push  the  stone  upwards,  and  retain  it  above  the 
symphysis  pubis,  until  the  head  could  get  below  it.  Should  the 
practitioner  arrive  late,  and  find  the  stone  coming  down  before  the 
head,  he  should,  notwithstanding,  endeavour  to  raise  it  above  the 
strait.  Where  it  is  impossible  to  get  it  up,  there  is  one  resource 
left,  which  is  to  cut  down  on  to  the  stone  through  the  anterior  side 
of  the  vagina,  or  to  perform  vaginal  lithotomy. 

924.  The  labia  or  nymphae  may  have  become  agglutinated  pos- 
teriorly to  the  fecundation,  and  either  wholly  or  partially  close  up 
the  vagina.  The  hymen  may  be  hard,  fibrous  or  cartilaginous,  so 
as  to  leave  but  a  small  orifice,  and  thus  interfere  with  the  escape  of 


400  DYSTOCIA. 

the  child  (143).  Delivery  is  not  in  such  cases  impossible  :  such 
feeble  barriers  are  incapable  of  counterbalancing  the  energetic 
contractions  of  the  uterus  ;  but  it  is  better  to  divide  with  an  in- 
strument those  parts  that  have  to  be  separated,  than  to  expose  the 
woman  to  the  risk  of  ruptures  and  irregular  lacerations  vphose 
limits  can  not  be  prescribed,  and  which  might  go  to  a  dangerous  ex- 
tent. 

925.  Where  the  vulvar  extremity  of  the  vagina  is  completely 
obliterated,  no  conception  could  possibly  have  taken  place  by  the 
natural  passages  ;  but  it  is  not  uncommon  to  meet  with  bridles  or 
partial  contractions  in  some  part  of  the  canal.  Where  these  frena 
are  not  very  old,  or  very  hard,  they  ordinarily  become  softened  and 
yield  to  the  mere  progress  of  the  labour ;  where  they  resist,  so  far 
as  to  awaken  a  fear  of  laceration  of  the  womb,  inertia,  convulsions, 
exhaustion,  or  their  own  rupture,  they  should  be  divided  by  making 
a  few  small  incisions  on  their  anterior  edges.  A  woman  who  was 
in  labour  of  her  third  child,  and  who  two  years  previously  was 
delivered  by  means  of  instruments,  was  brought  to  the  hospital  de 
Perfectionnement,  by  M.  Dubourguet,  after  having  been  three  days 
in  travail :  I  was  about  to  apply  the  forceps,  but  was  soon  arrested 
by  a  large  crescent-shaped  bridle,  which  was  hard,  and,  as  it  were, 
fibro-cartilaginous,  which  was  two  inches  above  the  vulva,  and  on 
the  free  edge  of  which  I  found  it  necessary  to  make  three  incisions. 

926.  When  the  vagina  opens  into  the  bladder,  fecundation  being 
on  that  account  evidently  impossible,  it  is  therefore  useless  to  class 
this  deviation  among  the  causes  of  dystocia. 

Several  authors,  and  among  others  Barbaut,  and  still  more  re- 
cently M.  Marc,  have  made  mention  of  women  in  whom  the  vagina 
opened  into  the  rectum,  who  notwithstanding  became  pregnant,  and 
yet  were  delivered  without  any  artificial  aid. 

Stegmann  relates  the  case  of  a  girl  whoso  vagina  opened  above 
the  pubis,  and  Morgagni  speaks,  after  Gianella,  of  a  case  in  which  fe- 
cundation nevertheless  took  place  :  in  such  a  case  it  would  be  neces- 
sary first  to  try,  like  the  Italian  accoucheur,  to  dilate  the  preternatu- 
ral opening,  and  should  that  prove  insufficient,  to  make  seyeral  eccen- 
tric incisions  upon  the  orifice,  not  losing  sight  of  the  proximity  of 
the  peritoneum  and  bladder. 

Scirrhous  or  fibfous  tumours  capable  of  affording  an  obstacle  to 
delivery,  and  requiring  serious  operations,  rarely  occur  in  the  vulva ; 
but  chronic  or  acute  phlegmons  are  met  with  that  might  be  singu- 
larly aggravated  by  the  passage  of  the  fcetus,  and  it  is  important, 
therefore,  that  they  should  bo  very  energetically^  treated  in  women 
who  arc  approaching  their  term. 


TUMOURS.  401 

.  The  labia  are,  at  limes,  the  seat  of  bloody  tumours^  o(  a  particu- 
lar kind,  that  I  have  long  mentioned  in  my  lectures,  which  Dr 
Dewees  also  has  described  in  the  American  journals,  and  to  the  con- 
sideration of  which  I  shall  return  when  I  come  to  treat  of  the  ac- 
cidents of  parturition  ;  for  the  present,  I  shall  content  myself  with 
stating,  that  where  they  are  sufficiently  large  to  interfere  manifestly 
with  the  birth  of  the  child,  or  expose  the  mother  to  very  acute 
suffering,  I  should  not  hesitate  about  plunging  a  bistoury  into  them, 
so  as  to  empty  them  completely. 

927.  Some  women,  though  in  other  respects  robust,  are  affected, 
towards  the  close  of  pregnancy,  with  a  considerable  infiltration  in 
the  lower  limbs,  and  even  in  the  whole  body.  The  cutaneous  and 
mucous  folds  of  the  vulva  may  in  such  cases  attain  to  an  enormous 
size,  and  completely  close  the  vagina  ;  the  termination  of  a  labour 
is  thus  rendered,  of  necessity,  much  more  difficult,  and  above  all 
much  more  painful ;  it  cannot  be  dissembled,  that  by  leaving  nature 
to  herself  here,  there  will  be  reason  to  fear  the  occurrence  of  gan- 
grene, or  of  more  or  less  extensive  lacerations  ;  unhappily,  although 
threatened  with  such  dangers,  there  is  little  tliat  the  accoucheur  can 
do  ;  some  punctures,  the  application  of  emollient  and  sedative 
lotions,  and  care  in  relation  to  the  disposition  of  the  parts  and  to 
the  muscular  efforts  of  the  woman,  afford  all  the  materials  for  his 
counsel. 

928.  Inversion  of  the  vagina  may  take  place  during  pregnancy 
and  even  during  labour.  I  was  called  last  spring,  by  Madame  Beva- 
let,  to  see  a  woman  who  had  been  suffering  for  thirty  hours  without 
being  delivered.  The  head  of  the  fcetus  was  quite  down  in  the  ex- 
cavation ;  but  the  vagina,  which  was  entirely  inverted,  exhibited  out- 
side of  the  vulva,  the  appearance  of  a  fungous  and  livid  cushion 
larger  than  two  fists.  It  was  necessary  to  apply  the  forceps  for  the 
delivery  of  the  patient. 

929.  Much  has  been  said  about  the  obliteration  of  the  os  uteri 
of  women  in  labour  ;  but  if  it  is  not  wholly  certain,  it  is  at  least 
highly  probable  that  the  authors  who  have  mentioned  it  were  mis- 
led by  some  deviation  affecting  the  os  tineas.  I  have  already  seen 
so  many  practitioners,  even  experienced  ones,  affirm  that  there  was 
no  OS  uteri  at  all,  in  cases  where  it  was  merely  raised  up  towards 
the  sacro-vertebral  angle,  that  it  seems  to  me  very  easy  to  refer  a 
great  majority  of  the  cases  of  supposed  obliteration  of  the  os  uteri 
to  this  mistake  alone.  It  is  evident  that  nothing  less  than  some 
severe  disease,  some  acute  inflammation,  could  thus  close  up  the 
mouth  of  the  womb,  betwixt  the  fecundation  and  the  term  of  gesta- 
tion ;  but  in  that  case  the  parts  would  necessarily  be  affected  with 

3  A 


402  DYSTOCIA. 

concomitant  alterations  of  structure,  sufficient  to  remove  all  doubts  ; . 
the  anamnestic  signs  would  have  attracted  attention  precedently, 
and  abortion  could  rarely  fail  to  take  place. 

However,  if  authentic  examples  be  wanting  of  complete  obliter- 
ation at  the  period  of  labour,  we  at  least  possess  several  instances 
of  coarctation,  partial  or  total  induration,  and  still  more  numerous 
ones  of  stricture  in  some  other  portion  of  the  os  uteri. 

Were  the  canal  closed  by  a  spongy  or  polypous  mass,  like  those 
met  with  by  Denman  and  M.  Evrat,  we  should  wait  for  its  descent 
into  the  vagina,  to  attempt  its  extraction,  after  which  we  should 
proceed  as  in  any  other  case  of  parturition.  * 

930.  A  scirrhous  induration^  of  partial  extent,  might  require  no 
particular  assistance.  In  a  case  mentioned  by  M.  Desormeaux,  the 
whole  dilatation  took  place  at  the  expense  of  only  two-thirds  of  the 
circumference  of  the  orifice,  and  the  escape  of  the  ovum  was 
scarcely  retarded ;  but  if  the  whole  of  the  cervix  uteri  were  involved, 
either  at  its  vaginal  extremity,  or  at  a  point  near  the  cavity  of  the 
uterus,  the  vaginal-cesarian  operation  would  be  indicated,  it  being 
well  understood  that  a  forced  dilatation  with  the  fingers  or  the 
speculum,  either  could  not  be  attempted,  or  had  been  vainly  tried. 

931.  A  fibrous  tumour,  a  scirrhus,  a  polypus,  cicatrices,  an  ulcer, 
an  abscess  in  the  substance  of  the  womb,  or  even  upon  its  internal 
substance,  would  also  require  particular  precautions,  provided  it 
were  possible  to  ascertain  their  existence.  In  the  first  place,  the 
diseased  point  does  not  in  general  partake  in  the  extension  of  the 
organ  during  pregnancy,  or  does  not  contract  again  after  delivery ; 
in  the  next  place,  it  deranges  or  interrupts  the  contractions  during 
labour,  and  in  that  way  favours  the  occurrence  of  convulsions,  lace- 
ration of  the  womb,  hemorrhage,  inertia,  and  general  exhaustion. 
In  order,  therefore,  to  protect  the  woman  ias  far  as  possible  from 
such  dangers,  it  would  be  necessary  to  extract  the  child,  without 
waiting  too  long,  either  by  the  hand  or  with  instruments. 

932.  Labour  is  also  sometimes  rendered  very  difficult,  and  even 
wholly  impossible,  by  means  of  displacements  and  deviations  of  the 
womb. 

There  are  instances  of  complete  prolapsus  which  did  not  prevent 
the  woman  from  being  fecundated ;  witness  the  peasant  woman 
mentioned  by  Morgagni.  In  other  cases,  the  falling  of  the  womb 
occurs  during  pregnancy.  In  both  cases,  provided  the  gestation 
goes  to  its  full  term,  it  is  possible  for  the  womb,  which  here  can  not 
be  seconded  by  the  abdominal  muscles,  to  deliver  itself  alone;  but 
it  is  also  possible  that  the  pains  should  prove  to  be  insufficient,  and 
thenceforth  prudence  requires  us  to  make  use  in  successioiT  of  de- 


DISPLACEMENTS  OF  THE  WOMB.  403 

^octions,  mucilages  and  ointments  of  an  emollient  nature,  and 
resort  to  the  dilatation  or  incision  of  the  edges  of  the  orifice,  and 
afterwards  bring  down  the  child's  feet. 

Sennertus  and  Ruysch  have  related  cases  of  hernia  of  the  womb, 
where  the  women  have,  notwithstanding,  become  pregnant;  but  every 
consideration  leads  to  the  belief  that  mistake  here  has  morje  than  on 
one  occasion  arisen  from  a  very  decided  anterior  obliquity  of  the 
womb. 

This  kind  of  displacement  forms,  in  the  opinion  of  several  authors, 
an  insurmountable  obstacle  to  the  spontaneous  termination  of  la- 
bour ;  so  that,  under  such  circumstances,  they  have  thought  of  no 
better  counsel  than  that  of  resorting  to  the  cesarian  operation  ;  how- 
ever, this  last  recourse  will  hardly  be  taken  by  a  man  who  is  fully 
acquainted  with  the  resources  of  the  animal  economy.  Provided  the 
reduction  be  possible,  the  accoucheur  will  attempt  it ;  in  the  con- 
trary case,  he  should  be  content  with  recommend'mg  the  horizontal 
posture,  and  advising  the  woman  not  to  bear  down.  During  the 
contractions,  and  even  during  the  intervals  between  them,  it  is  pro- 
per to  press  the  uterus  backwards,  with  the  two  hands  applied  to  the 
epigastrium,  as  if  to  make  it  re-enter  the  abdomen  ;  by  means  of 
these  precautions,  which  are  not  even  always  indispensable,  the  os 
uteri  dilates,  opens,  and  the  labour  most  frequently  terminates  with- 
out further  assistance,  and  without  danger,  even  in  cases  apparently 
the  most  difficult.  An  accoucheur  at  Copenhagen  was  called  to  a 
woman  who  had  for  a  long  time  had  a  crural  hysterocele,  and  who 
exhibited  some  symptoms  of  pregnancy ;  the  period  of  delivery  ar- 
rived, the  surgeon  had  given  the  most  unfavourable  prognosis,  and 
thought  he  should  be  tinder  the  necessity  of  performing  the  opera- 
tion of  hysterotomy.  But  nothing  of  the  kind  happened,  and  the 
labour  terminated  spontaneously.  Ruysch  and  Simon  relate  two 
cases  of  uterine  hernia  equally  remarkable  :  in  one  of  them  the  ce- 
sarian operation  was  performed  and  the  woman  died  ;  in  the  other, 
nothing  was  done,  and  both  the  mother  and  child  were  saved ! 

Simple  deviations  of  the  womb  may  also  interfere  with  the  pro- 
gress of  parturition  and  require  some  particular  care.  Upon  this 
subject  I  ought  to  remark,  that  it  is  far  more  important  than  writers 
seem  to  suppose,  not  to  confuse  deviations  of  the  cervix  with  those 
of  the  womb  strictly  so  called;  In  fact,  although  the  deviation  of 
the  orifice  pretty  frequently  coincides  with  that  of  the  Amdus  of  the 
organ,  i*  is  nevertheless  undeniable,  that  one  is  often  met  with  with- 
out the  other. 

933.  When  the  womb  is  inclined  laterally  or  backwards,  no  great 
difficulty  can  arise  as  to  the  delivery  of  the  child,  provided  there 


404  DYSTOCIA. 

should  be  no  other  cause  of  dystocia.  In  the  anterior  obliquity,  on 
the  contrary,  especially  when  it  is  to  a  great  extent,  the  assistance 
of  art  may  become  indispensably  necessary.  The  woman  should 
be  directed  to  lie  down  at  the  very  beginning  of  the  labour,  and  told 
to  remain  in  a  horizontal  posture,  taking  care  to  keep  the  hips  con- 
siderably elevated ;  the  hypogastrium  is  to  be  pressed  backwards, 
while  by  means  of  one  or  two  fingers  introduced  into  the  vagina  we 
attempt  to  draw  the  os  uteri  to  the  centre  of  the  pelvis.  These  last- 
mentioned  tractions,  which  are  useful  where  the  orifice  is  found 
raised  upwards  towards  the  sacro-vertebral  angle,  need  not  be  tried 
in  cases  where  the  womb,  instead  of  being  inclined  by  a  see-saw 
motion,  is  bent  forwards  on  its  anterior  surface,  like  a  chemist's 
retort  ?  But  in  that  case  we  should  direct  the  woman  to  mode- 
rate, or  even  to  suspend,  her  efforts ;  for,  during  the  pains,  the  ac- 
tion of  the  diaphragm  and  abdominal  muscles  tends  constantly  to 
augment  the  obliquity,  and  thus  to  annul  the  efforts  of  the  practi- 
tioner in  a  contrary  direction.  In  the  spring  of  1825  I  was  called 
by  M.  Majeste  to  a  woman  whose  labour  had  been  at  a  stand  for 
several  hours,  notwithstanding  the  pains  were  very  severe.  The 
womb,  bent  into  the  form  of  a  retort,  was  so  disposed  that  at  each 
contraction  its  posterior  surface  became  quite  horizontal.  I  showed 
the  patient  that  her  efforts  were  not  only  of  no  use,  but  also  that 
they  were  sufficient  to  prevent  her  labour  from  coming  to  a  conclu- 
sion. She  was  obedient  to  the  counsel  I  gave  her,  and  resisted,  as 
far  as  she  possibly  could,  the  sensations  that  excited  her  to  bear  down. 
It  was  not  long  before  the  womb  rose  up  of  its  own  accord  during 
the  contraction,  the  head  soon  engaged,  and  in  two  hours  after- 
wards the  child  was  born.  There  are,  therefore,  certain  cases  of 
inclination  where  the  labour  ought  to  be  abandoned  almost  entirely 
to  the  mere  contractions  of  the  womb. 

934.  Doubtless,  Moschion  and  Deventer  were  wrong  in  main- 
taining that  obliquity  of  the  womb  most  frequently  produces  a  trans- 
verse position  of  the  foetus  ;  but  it  would  be  quite  as  unreasonable 
to  maintain  that  this  effect  never  does  take  place.  If  the  inclina- 
tions of  the  w;omb  do  rarely  suflUce  to  produce  real  transverse  or 
shoulder  presentations  of  the  foetus,  they,  at  least,  seem  to  me  to  be 
very  frequently  the  causes  of  presentations  of  the  face,  the  forehead, 
the  nucha,  the  parietal  protuberances,  the  hips,  &c.  and  in  this  res- 
pect to  deserve  the  attention  of  the  accoucheur.  ♦ 

935.  I  ought  in  this  place  to  mention  a  kind  of  deviation  that  I 
have  never  met  with  but  once,  of  which  I  have  been  unable  to  find 
any  cases  described  by  the  various^ authors,  and  which  o\ight  not  to 
be  confounded  with  anterior  obliquity.     In  a  woman  who  came  to 


DISPLACEMENTS  OF  THE  WOMB. 

be  confined  at  noy  amphitheatre  in  the  month  of  May  1828,  the 
fundus  of  the  uterus  was  rather  inclined  backwards  than  forwards; 
the  head  of  the  foetus  formed  above  the  strait  a  considerable  projec- 
tion, which  descended  nearly  to  the  vulva,  and  was  at  last  situated  in 
front  of  the  symphysis  pubis  ;  the  os  uteri,  which  was  on  a  level  with 
the  superior  strait,  seemed  to  be  scooped  out  of  the  substance  of  the 
posterior  wall  of  the  womb,  which  made  it  much  longer  behind  than 
before  ;  in  order  to  reach  the  orifice  and  penetrate  towards  the  head 
of  the  child,  I  was  obliged  to  bend  my  finger  so  as  to  make  it  pass 
almost  horizontally  above  the  pubis.  Such  a  state  of  things  sur- 
prised me,  and  I  mentioned  it  to  the  students,  who  easily  satisfied 
themselves  as  to  its  existence.  The  progress  of  the  labour  was  so 
much  retarded  by  it,  that  after  seven  hours  of  pain  and  pretty  strong 
contractions,  the  os  uteri,  although  very  soft  and  very  dilatable,  was 
scarcely  opened  at  all.  M.  Desorraeaux,  whom  I  invited  to  see  this 
remarkable  case,  said  that  he  had  never  noticed  one  like  it,  and 
agreed  with  me  that  by  means  of  position  and  the  assistance  of  the 
hand  properly  connbined,  I  ought  to  try  to  carry  the  head  to  the 
centre  of  the  superior  strait,  by  making  it  slide  from  below  upwards 
and  from  before  backwards  over  the  pubis.  I  began  to  execute 
this  maneuvre  at  half  past  eight  o'clock,  and  continued  it,  alternat- 
ing with  several  of  the  students  until  nine  o'clock.  From  this  time 
there  was  no  longer  a  tumour  in  front  of  the  symphysis,  and  the 
labour  progressed  so  rapidly  that  in  less  than  an  hour  the  child  was 
born  and  the  placenta  itself  expelled. 

Such  a  state  of  things  seems  to  depend :  1st,  on  a  posterior 
inclination  of  the  womb ;  2d,  on  excessive  inclination  of  the  supe- 
rior strait ;  3d,  on  some  deviated  position  of  the  fostal  head,  and, 
perhaps,  upon  the  thickness,  or  the  unequal  density  of  the  walls  of 
the  womb;  to  this  displacement  should  be  referred  the  positions 
described  under  the  name  of  sur-pubal  by  Madame  Lachapelle  and 
M.  Duges. 

936.  I  have  many  times  found  the  orifice  turned  so  much  back- 
wards or  to  the  outside,  that  its  plane  was  almost  parallel  to  the  axis 
of  the  woman's  body,  although  the  rest  of  the  womb  was  scarcely 
deviated  at  all.  Excessive  amplitude  of  the  pelvis,  great  inclination 
of  its  superior  strait,  anjfclpresentations  of  the  vertex,  are  probably 
the'causes  that  most  favour  its  obliquity.  In  touching,  we  feel, 
sometimes  almost  at  the  bottom  of  the  excavation,  and  at  others 
rather  higher  up,  a  tumour,  generally  very  even,  and  which  consists 
qf  the  child's  head  covered  with  the  anterior  wall  of  the  distended 
cervix  of  the  uterus.  This  state  of  things  has  to  me  seemed  to  im- 
press upon  labour  a  peculiar  character  of  tediousness,  and  often 


406  DYSTOCIA. 

coincides  with  what  is  called  pains  in  the  reins.  The  ablest  wri- 
ters, and  Baudelocque  himself,  recommend,  as  a  remedy,  that  we 
should  hook  the  os  uteri  with  one  or  two  fingers,  draw  it  towards 
the  centre  of  the  pelvis  during  the  intervals  between  the  pains,  and 
keep  it  there  during  the  contractions ;  or  also,  have  recourse  to 
vaginal  hysterotomy,  the  only  means  of  avoiding  gangrene  or  rupture 
of  the  womb,  &c.  Were  I  to  depend  upon  my  own  experience  in 
this  matter,  I  should  be  led  to  think  that  the  interference  of  art,  in 
this  state  of  things,  is  rarely  necessary,  and  that  in  more  than  one 
case  there  has  been  too  great  haste  in  acting,  to  the  great  detriment 
both  of  the  mother  and  child.  I  for  a  long  time  conformed  to  the 
precepts  laid  down  in  the  books,  I  pulled  at  the  os  uteri,  and  did 
all  I  could  to  bring  it  back  to  the  centre  of  the  excavation  ;  it  is  true 
I  succeeded,  but  pretty  often  not  until  I  had  remained  several  hours 
with  the  woman.  I  was  one  day  obliged  to  leave  a  student  as  my 
substitute,  who  neglected  the  directions  I  gave  him ;  after  an  ab- 
sence of  three  hours  I  returned,  found  the  os  uteri  completely 
dilated,  the  membranes  ruptured,  and  the  head  strongly  engaged. 
From  that  time  I  have  never  interfered  in  such  cases,  and  the 
organism  has  always  succeeded  in  restoring  things  to  their  natural 
state.  My  design  ia  not  to  conclude  from  this,  that  we  must  never 
do  any  thing  but  wait,  but  merely  to  observe,  that,  excepting  in  a 
small  number  of  cases,  nature  herself  may  suffice,  and  that  a  resort 
to  bloody  operations  ought  not  to  be  lightly  resolved  on. 

937.  Gibbosities  and  acute  diseases  do  not  become  a  cause  of 
dystocia,  excepting  as  they  often  do  not  allow  the  woman,  without 
danger,  to  give  herself  up  to  the  efforts  needed  for  the  delivery  of  a 
child ;  but  there  is  another  very  remarkable  cause  of  difficult  labour 
which  no  author  has  mentioned.  A  strong,  robust  woman,  pregnant 
with  her  first  child,  in  the  forty-fifth  year  of  her  age,  had  been  in 
labour  for  forty  hours,  when  M.  Morisse  sent  for  me  to  see  lier. 
The  presentation  was  good,  the  head  had  been  in  the  excavation  for 
twelve  hours  without  advancing,  in  spite  of  the  energy  of  the  uterine 
contractions.  The  skin  on  the  fore  part  of  the  thighs  and  abdomen 
was  all  covered  with  old  cicatrices,  which  were  hard  and  fibrous, 
and  confined  the  lower  part  of  the  hypogastrium,  so  that  the  womb 
was  as  if  strangulated  immediately  aboife  the  pubis,  and  the  child 
could  not  descend.  I  applied  the  forceps,  and  the  child  was  brought 
away  living. 

§.  II.  Dystocia  depending  on  the  foetus.     Monstrosity. 

938.  Excessive  volume.     There  is  no  doubt,  says  M.  Duges,  that 
where  the  cliild  is  very  tall  it  may  render  a  labour  more  tedious, 


MONSTROUS  F(ETUS.  407 

painful  and  distressing,  especially  if  the  passages  are  not  soft  and 
small,  as  in  a  first  labour  ;  but  it  is  not  yet  proved  that  great  size  in 
a  well  formed  child  at  full  term  has  ever  alone  constituted  an  in- 
surmountable  obstacle  to  spontaneous  parturition. 

If  it  be  true  that  Baudelocque,  Chaussier,  M.  Capuron,  &c.  have 
seen  children  born,  weighing  near  thirteen,  twelve,  or  even  ten 
pounds,  it  is  nevertheless  certain  that  we  no  longer  see  them  reach- 
ing to  the  weight  of  fifteen,  twenty,  and  twenty-five  pounds,  nor  any 
whose  length  exceeds  from  twenty-two  to  twenty-three  inches.  But, 
as  it  is  an  easy  matter  to  -ascertain  that  the  head  of  a  foetus  of 
twenty-two  inches  will  not  be  quite  four  inches  in  its  occipito- 
bregmatic  and  bi-parietal  diameters,  it  is  at  once  evident  that, 
even  in  case  of  extreme  size,  spontaneous  delivery  is  not  impos- 
sible. It  should  be  remarked,  however,  that  in  that  case  the  least 
narrowness  of  the  pelvic  cavity,  especially  in  the  perineal  strait,  must 
promptly  become  the  cause  of  dystocia. 

On  the  other  hand,  the  practitioner  ought  to  know  that  under  such 
circumstances,  version  by  the  feet  is  never  proper.  Indeed,  where 
the  head  presents,  although  its  shortest  diameter  and  smallest  cir- 
cumference are  almost  always  in  relation  with  the  largest  diameters 
of  the  pelvis,  it  is  rarely  that  in  extracting  the  child  by  the  feet  the 
occiput  is  not  forced  to  turn  over  more  or  less  upon  the  back,  while 
the  occipito-frontal,  which  would  be  nearly  five  inches  long,  would 
take  place  of  the  occipito-bregmatic  diameter ;  perhaps  it  might  even 
be  the  occipito-mental  that  would  be  thus  situated,  and  that  would 
be  at  least  five  and  a  half  inches  in  length. 

The  best  course  is  to  confide  in  the  resources  of  the  organism, 
and  where  it  is  indispensably  necessary  to  act,  to  attempt  the  appli- 
cation of  the  forceps  rather  than  venture  upon  turning ;  and  should 
it  be  a  presentation  of  the  pelvic  extremity  of  the  foetus,  either  ori- 
ginally or  by  turning,  every  precaution  should  be  employed  to  pre- 
vent an  arm  from  becoming  locked  behind  the  neck. 

939.  Infiltration  of  the  integuments  of  the  head,  and  sanguine 
tumours,  sometimes  evidently  increase  the  size  of  the  head,  but 
rarely  to  such  an  extent  as  to  furnish  any  real  obstacle  to  delivery. 
Harnier,  to  be  sure,  has  remarked  that  where  thrombuses  and  in- 
filtrations are  of  such  magnitude  as  to  deserve  any  particular  atten- 
tion, by  engaging  in  the  space  under  the  arch  of  the  pubis,  such 
tumours  prevent  the  rotation  movement  which  the  head  ought  to 
execute  in  order  to  clear  the  inferior  strait. 

940.  Hydrocephalus  constitutes  a  much  more  real,  and  particu- 
larly much  more  serious  cause  of  dystocia ;  it  is  recognized  by 
various  signs :  the  finger  feels  a  broad  and  tense  tumour ;  the  bones 


408  DYSTOCIA. 

of  the  head  are  evidently  separated  and  very  movable ;  the  dimen" 
sions  of  the  fontanels  are  very  considerable ;  sometimes  we  meet 
with  Wormian  bones  of  various  sizes  in  the  midst  of  spaces  that  are 
completely  membranous;  as  to  the  infiltration  of  the  limbs  and 
hypogastrium  of  the  mother  during  gestation,  ascites,  hydramnios, 
anasarca,  the  lymphatic  constitution,  and  the  rational  signs,  that 
have  been  supposed  derivable  from  the  size  of  the  head,  tongue, 
and  forehead  of  the  woman,  they  can  give  rise  only  to  conjec- 
tures that  are  wholly  useless  in  the  establishment  of  a  positive  diag- 
nosis. Moreover,  it  is  necessary  to  tstke  care  not  to  be  imposed 
upon  by  an  accidental  deficiency  of  ossification,  by  a  fontanel,  by 
abnormal  sutures,  or  a  great  degree  of  flexibility  of  the  bones,  and 
to  recollect  that  hydrocephalus  during  intra-uterine  life  is  so  rare, 
that  according  to  Madame  Lachapelle  and  M.  Duges  it  was  only 
met  with  fifteen  times  in  43,65i  labours. 

941.  In  order  to  comprehend  the  dangers  of  this  species  of  dys- 
tocia, it  should  be  well  understood  that  serous  fluids  may  accumu- 
late in  various  quantity  in  the  cranium,  and  that  if  the  head  is  sod 
and  its  size  not  very  greatly  augmented,  the  mere  energies  of  the 
woman  in  general  sufiice  for  its  expulsion.  When  its  size  is  not 
excessive  and  the  womb  threatens  to  fall  into  inertia,  recourse  is 
had  to  the  forceps,  taking  care  to  make  use  of  a  moderate  degree 
of  pressure,  so  as  not  to  burst  the  head,  nor  allow  of  the  instrument's 
slipping.  Where  the  child  is  dead  and  the  head  is  too  large  to  get 
through  the  straits,  cephalotomy  becomes  a  last  resource,  which 
we  are  obliged  to  employ. 

Notwithstanding,  I  ought  not  to  conceal  that  this  subject  has 
been  and  still  is  the  subject  of  a  very  important  question  among 
practitioners.  Where  we  have  a  certainty  that  the  child  is  .dead, 
every  body  is  agreed  ;  but  in  the  contrary  case,  it  has  been  asserted 
that  we  have  no  right  to  kill  it,  and  that  it  would  be  better  to  per- 
form the  cesarean  operation  or  symphyseotomy.  Others  halve  ob- 
jected that  a  child  ought  not  to  be  the  assassin  of  its  mother ;  that 
as  hydrocephalous  children  die  very  soon  after  their  birth,  it  would 
be  contrary  to  humanity  ap  well  as  to  morality  to  sacrifice  a  sound 
and  healthy  woman  for  a  being  whose  existence  is  so  precarious. 
These  reasons  are,  in  my  opinion,  of  the  highest  authority ;  for 
although,  as  M.  Duges  asserts,  it  be  true  that  a  slight  degree  of 
hydrocephalus  ought  not  necessarily  to  occasion  the  death  of  the 
child,  does  not  always  prevent  its  viability,  and  may  sometimes  be 
cured,  it  is  equally  certain,  that  in  case  the  head  is  not  so  large  as 
absolutely  to  require  the  operation,  and  t  hat  where  even  the  diseae 
is  «o  advanced  as  to  render  the  delivery  impossible,  we  have  no 


MONSTROUS  FffiTUS.  409 

ground  to  rely  upon  the  viability  of  the  child.  But  how  is  the 
liquor  amnii  to  be  evacuated  ?  Should  it  be  done  with  Smellie's 
scissors,  Stein's  perce-crdne,  a  common  bistoury,  or  is  it  better,  like 
MM.  Maygrier  and  Duges,  to  be  content  with  a  simple  trocar  ? 
Since,  according  to  Holbrociv,  Vose,  &c.  the  puncture  has  been 
successfully  performed  after  birth,  and  as  large  lacerations  are  not 
required  to  give  issue  to  the  serum  of  hydrocephalus,  I  perceive  no 
inconvenience  likely  to  arise  in  pursuing  this  last  named  course, 
inasmuch  as  it  at  once  satisfies  the  indications  of  prudence  and  the 
wants  of  practice.  But  if  the  head  should  not  be  thereby  emptied 
sufficiently  to  render  its  escape  easy,  I  should  not  hesitate  about 
plunging  one  of  the  other  instruments  into  the  head. 

After  the  operation  of  cephalotomy  has  been  performed,  the  con- 
tractions of  the  womb  generally  suffice  for  the  expulsion  of  the  head  ; 
but  if  this  should  not  be  the  case,  recourse  is  had  to  the  forceps,  to 
turning,  or  to  the  crotchet. 

942.  I  do  not  know  that  hydro-rachis  has  ever  proved  to  be  a  real 
obstacle  to  the  termination  of  a  labour.  It  is  a  dangerous  disease 
to  the  foetus,  and  that  is  all ;  besides,  nothing  could  be  easier  than 
to  empty  the  tumour  by  pushing  a  trocar  into  it,  should  it  appear  to 
interrupt  the  progress  of  the  labour. 

943.  It  is  rare  also  for  ascites^  and  particularly  for  hydrothorax^  to 
be  of  such  extent  as  to  furnish  considerable  obstacles  to  the  delivery 
of  thechild,  asappears  from  the  remarks  of  Baudelocque,  M.  Lamour- 
eux,  and  M.  Duges.  In  all  cases  those  lacerations  and  eviscerations 
that  were  practised  by  Deventer  should  be  avoided,  as  well  as  the 
mode  recommended  by  P/lauriceau,  of  perforating  the  navel  or  tho 
neighbouring  parts  with  the  finger  ;  simple  punctures,  made  with  a 
trocar  or  a  bistoury,  always  suffice  to  produce  the  efiect  which  it  is 
desirable  to  obtain. 

944.  Solid  tumours  developed  upon  certain  parts  of  the  trunk, 
or  any  decided  deformity,  like  the  case  related  by  Baudelocque,  and 
another  one  published  by  M.  Nivert,  might  require  some  peculiar 
attention,  or  even  render  delivery  wholly  impossible.  Cases  of  this 
sort  are  particularly  untoward,  inasmuch  as  it  is,  generally,  qui 
impossible  to  ascertain  the  circumstances  until  after  delivery.  Th 
in  the  case  that  fell  under  M.  Nivert's  notice,  the  foitus  had  a  ve: 
solid  and  projecting  gibbosity  which  lodged  above  the  pubis  ;  the  for^' 
ceps  was  applied,  but  without  effect,  for  it.  became  necessary  to  empty 
the  head  ;  still,  it  was  only  by  means  of  the  crotchet  and  by  employ- 
ing the  utmost  strength,  that  he  succeeded  in  extracting  the  trunk 
of  the  fcetus.  Who  could  have  suspected  tlie  existence  of  such  an 
obstacle  ?  and  even  had  it  been  understood,  what  could  have  been 

3  B 


nis 


410  DYSTOCIA. 

done  ?  Ought  turning  to  have  been  attempted  ?  Would  any  ad- 
vantage have  been  derived  from  pressure  suitably  applied  to  the 
lower  part  of  the  hypogastrium  ?  It  belongs  to  future  experience 
to  solve  these  questions. 

945.  The  simultaneous  presence  o[  several  fostuses  in  the  womb 
is  far  from  always  being  a  cause  of  dystocia,  especially  when  they 
are  independent  of  each  other,  and  are  each  enclosed  within  a 
separate  amnios.  But  this  is  not  the  case  where  they  are  contained 
within  the  same  set  of  membranes,  or  have  contracted  any  adhesions 
that  compel  them  to  present  simultaneously  at  the  straits  of  the 
pelvis. 

In  the  latter  case,  the  union  of  the  children  may  be  in  very  vari- 
ous degrees.  Sometimes  they  are  connected  together  by  a  very 
circumscribed  point  upon  the  inferior,  middle  or  superior  part  of  the 
back,  sometimes  by  almost  the  whole  back,  side,  or  front  ;  at  others 
they  are  conjoined  at  the  head,  or  placed  end  to  end  at  the  breech. 
The  fusion  is  in  some  cases  much  more  complete  :  or,  there  may 
be  only  one  single  trunk  to  two  heads  and  two  or  four  arms  ;  or,  on 
the  contrary,  there  may  be  only  one  head  to  two  trunks,  with  limbs 
more  or  less  completely  isolated. 

94 G.  The  signs  of  these  monstrosities  are  so  vague,  that  they 
really  do  not  deserve  to  be  repeated  in  this  place  ;  there  can  be  no 
certainty,  nor  even  probability,  of  their  existence,  except  in  so  far 
as  certain  portions  of  the  fu3tus  are  already  emerged  ;  and  even 
then,  it  is  for  the  most  part  very  difficult  to  characterise  the  nature 
of  the  monster  we  are  about  to  receive. 

We  have  enough  of  cases  of  monsters  from  excess  of  parts,  born 
living  and  under  tlie  mere  resources  of  nature,  to  warrant  us  in  not 
acting  too  hastily  in  such  circumstances.  If  a  double  foetus  with 
a  single  head  presents  by  the  vertex,  or  even  by  the  feet,  provided 
the  conformation  of  the  pelvis  be  good,  the  delivery  will  not  require 
any  i)articular  interference;  the  same  would  be  the  case  with  two 
foetuses  attached  to  each  other  by  their  extremities,  either  the  head 
or  breech,  as  is  proved  by  the  cases  mentioned  by  Meckel,  Palfyn, 
Duverney,  Home,  &c.  Further,  M.  Dugcs  saw  one  born  without 
assistance,  though  it  was  completely  double,  at  full  term,  and  of 
large  size.  But  again,  the  observations  of  Plenck,  Smellie,  &.c. 
demonstrate  that  monsters  of  a  much  smaller  size  have,  on  more 
than  one  occasion,  rendered  delivery  very  distressing,  both  to  the 
mother  and  the  accoucheur,  particularly  where  there  was  a  great 
desire  to  have  them  born  alive. 

947.  When  there  are  two  heads  to  a  single  trunk,  provided  the 
one  that  is  in  front  succeeds  in  engaging  first,  the  second  may  fol- 
low without  any  extreme  difficulty,  and  being  forced  downwards, 


MONSTERS.  411 

they  will  clear  the  vulva,  almost  as  easily  aa  if  there  had  been  but 
one.  When  such  a  monster  presents  by  the  feet,  the  posterior  head 
ought  to  descend  first  into  the  excavation,  whilst  the  other  remains 
above  the  pubis ;  the  woman  may  exhaust  herself  in  vain  efibrts, 
and  the  intervention  of  the  accoucheur  may  become  indispensable. 
But,  previously  to  operating,  several  questions  present  themselves 
to  the  practitioner  ;  is  the  monster  dead,  or  is  it  living  ?  In  the  lat- 
ter case,  are  we  to  act  upon  the  woman,  or  upon  the  fcctus  ?  I 
know  that  a  double  child,  or  one  that  is  simply  bi-cephalous,  may 
live  and  grow  after  birth  ;  that  several  have  lived  for  seventeen,  or 
twenty  years,  and  even  to  a  very  advanced  age  ;  that  a  foetus  seen 
by  Everard  Home,  that  was  born  in  the  East  Indies,  and  which  died 
at  three  years  of  age  of  the  bite  of  a  serpent,  grew  as  regularly  as 
the  best  formed  child,  though  it  had  two  heads  united  together  at  the 
tertex.  Who  is  unacquainted  with  the  history  of  the  monster 
noticed  in  China,  and  of  which  an  account  was  laid  before  the 
Academic  des  Sciences  last  year  ?  I  do  not  wish  therefore  to 
maintain  that  such  beings  are  of  necessity  unlikely  to  live  ;  but  is  it 
true  that  they  have  the  same  rights  as  any  other  foetuses  to  our  care 
and  solicitude  ?  Is  their  life  so  valuable,  that  with  the  view,  and 
under  the  few  chances  of  preserving  and  raising  them,  we  are  bound 
to  perform  on  the  mother  a  most  dangerous  and  too  commonly 
fatal  operation  ?  I  am  aware  that  by  the  cesarian  operation  we 
may  save  the  child,  and  not  cause  the  mother  to  perish  ;  but  is  it 
not  well  known  that  one  half  of  the  women  who  submit  to  it  lose 
their  lives,  and  that  almost  all  the  foetuses  soon  undergo  the  same 
fate  ?  I  do  not  hesitate  to  say,  and  I  believe  in  conformity  to  the 
sacred  laws  of  humanity,  that  if  I  were  obHged  to  choose  between 
hysterotomy  and  the  murder  (meurtre)  of  a  monster,  I  should  not 
vacillate  a  moment,  I  would  sacrifice  the  foetus.  Happily,  the  skil- 
ful accoucheur  can  scarcely  ever  be  subjected  to  Ihis  distressing 
alternative  ;  maneuvres  well  arranged,  and  performed  either  with 
the  hand,  the  forceps,  or  the  lever,  almost  always  succeed  in  disem- 
barrassing the  woman  through  the  natural  passages,  without  injuring 
the  child. 

948.  The  turning  and  delivery  by  the  feet  resorted  to  by  Pen, 
Walter,  Walgen,  M.  Evrat,  M.  Brez,  Regnoli,  &,c.  and  recom- 
mended by  Asdrubali,  MM.  Desormcaux,  Dugcs  and  others,  whe- 
ther the  child  be  exactly  double  or  merely  bi-cephalous,  living  or 
dead,  and  at  any  stage  of  gestation,  will  suftice  in  nine  cases  out  of 
ten,  at  least,  where  there  are  no  other  causes  of  dystocia  present. 
It  ought  therefore  to  be  tried  in  all  cases.     However,  if  one  of  the 

heads  should  be  already  so  far  engaged,  that  it  could  not  possibly  be 

* 


I 


4f2  DYSTOCIA. 

returned,  we  might,  after  the  manner  of  Plenck,  try  the  application 
of  the  forceps.  Should  the  forceps  prove  insufficient,  there  would 
be  a  last  recourse,  the  removal  of  the  parts  that  had  descended  into 
the  excavation,  that  is  to  say,  of  the  head  alone,  or  the  head  and 
arms ;  after  which  the  feet  could  be  brought  down  so  as  to  deliver 
by  turning,  as  was  done  by  M.  Retel,  in  1818,  in  such  a  case. 
There  would  be  less  to  fear  in  such  a  case,  as  the  foetus  generally 
dies  long  before  we  are  reduced  to  this  extremity.  The  difficulty  of 
separating  two  children,  united  to  a  certain  extent,  outside  of  the 
womb,  and  the  danger  to  which  by  such  operations  they  are  exposed, 
clearly  show  how  imprudent  it  would  be  to  follow  the  advice  of  Smel- 
lie,  and  attempt  to  do  so,  in  the  interior  even  of  the  uterus. 

949.  When,  in  twin  pregnancy,  two  foetuses  present  simulta- 
neously at  the  straits,  the  intervention  of  art  almost  always  becomes 
necessary,  and  sometimes  indispensable.  If  it  be  found  that  both 
the  heads  tend  to  engage  at  the  same  time,  which  is  excessively  rare, 
it  is  proper  to  push  up  the  most  movable  one  with  the  fingers,  so  as 
to  let  the  other  advance  first ;  the  same  procedure  may  be  adopted 
for  the  feet,  the  knees  or  breech ;  if  the  children  present  across,  or 
in  any  other  way  except  by  the  head  or  the  pelvis,  recourse  must  be 
had  to  turning ;  but  it  may  happen  that  one  of  them  conies  by  the 
head,  whilst  the  other  descends  by  the  feet,  and  that  upon  reaching 
the  superior  strait  the  chin  of  the  latter  hooks  in  with  the  chin  of 
the  former,  so  that  the  two  heads  at  length  become  immovably  fixed, 
each  opposing  an  insurmountable  resistance  to  the  other,  and  con- 
stituting one  of  the  most  embarrassing  cases  in  the  practice  of  mid- 
wifery ;  neither  turning  nor  the  application  of  the  forceps  can  be 
thought  of;  even  the  cesarean  operation  itself,  which  has  been  re- 
commended by  some  authors,  would  not  always  enable  us  to  disengage 
the  foetus;  so  that  the  detruncation  of  the  one  that  is  without,  consti- 
tutes almost  the  only  resource  left  to  us  for  the  safety  of  the  mother 
and  one  of  the  children. 


i^^^ 


SECTION  3. 
Dystocia  from  Wrong  Presentations  of  the  Foetus. 


It  has  been  seen  in  another  article  that  the  presence  of  one  of  the 
extremities  of  the  occipito-coccygeal  diameter  of  the  foetus  at  the 
superior  strait,  is  one  of  the  first  conditions  of  eutocia .  All  the  cases 
in  which  any  other  point  than  the  head  or  pelvis  presents  ought 


WRONG  PRESENTATIONS.  413 

therefore  to  be  classed  among  the  cases  of  dystocia.  I  will  add  that 
to  tliem  should  be  conjoined  all  the  deviated  positions  of  the  head 
or  breech. 

§.  I.  Deviated  positions  of  the  head. 

Under  this  title  I  comprise  the  positions  of  the  sides  of  the  head, 
of  the  ears  or  of  the  temples,  admitted  by  Mauriceau,  Deventer,  De 
la  Motte,  and  Baudelocquc ;  and  those  of  the  occiput,  in  so  far  as  they 
really  exist,  as  was  understood  by  the  last  named  author :  as  to  the 
forehead  and  face  positions,  since  they  do  not,  in  general,  prevent  a 
labour  from  terminating  without  assistance,  I  shall  say  nothing  about 
them  in  this  place. 

950.  Positions  of  the  occiput  or  upper  part  of  the  nucha  are  rare,  and 
scarcely  occur  except  in  very  decided  anterior  inclination  of  the  womb. 
Then  the  vertex  may  be  turned  towards  some  point  on  the  circum- 
ference of  the  pelvis  instead  of  corresponding  to  the  centre  of  the 
strait ;  should  pushing  the  womb  backwards,  keeping  the  woman  on 
her  back,  or  the  mere  efforts  of  the  organism  prove  to  be  insufficient 
to  re-establish  the  natural  position,  it  would  be  necessary,  with  the 
fingers,  the  lever,  or  one  of  the  blades  of  th^  forceps,  to  hook  the 
uppef  part  of  the  cranium,  and  draw  it  down  towards  the  centre  of 
the  excavation,  upon  which  the  labour  would  return  to  the  natural 
order. 

961.  The  lateral  positions  of  the  head,  being  nothing  more  than 
slightly  modified  positions  of  the  vertex,  are  the  same  in  point  of 
number  with  them ;  they  are  marked  by  the  presence  of  the  ear,  of 
the  angle  of  the  jaw,  or  the  parietal  protuberance :  they  are  distin- 
guished from  each  other  by  considering  to  which  point  of  the  strait 
the  posterior  edge  and  lobule  of  the  ear  are  turned ;  they  are,  more- 
over, rare,  and  generally  end  in  conforming  themselves,  spontane- 
ously, to  the  corresponding  positions  of  the  vertex  or  shoulder. 

We  ought,  consequently,  to  trust  to  the  efforts  of  the  womb,  as 
long  as  the  os  uteri  continues  to  be  sufficiently  dilated ;  iC  they  then 
persist,  we  must,  as  in  positions  of  the  occiput,  endeavour  to  bring 
back  the  vertex  to  the  centre,  by  means  of  the  fingers,  the  lever,  or 
one  branch  of  the  forceps ;  or,  where  it  is  a  shoulder  that  is  too  far 
advanced,  the  child  should  be  turned  and  dehvered. 

§.  II.  Deviated  breech  positions. 

962.  The  pelvis  maiy,  like  the  vertex,  incline  in  any  direction,  and 
give  rise  to  what  have,  by  the  authors,  been  denominated  positions  of 
the  hips,  sacrum,  front  of  the  thighs,  and  genital  organs.     Produced 

sometimes  by  the  inclination  of  the  child  no  longer  agreeing  with  the 

^? 


414 


DYSTOCIA. 


vertical  axis  of  the  womb,  and  sometimes,  which  is  more  common, 
by  obliquities  of  the  uterus,  the  deviated  positions  of  the  breech  do 
not  always  prove  insurmountable  obstacles  to  spontaneous  delivery. 
Nature  often  succeeds,  alone,  in  transforming  them  into  direct  posi- 
tions, so  that  if  the  labour  progresses  in  other  respe.cts  regularly, 
the  assistance  of  art  rarely  becomes  necessary. 

However,  we  must  not,  for  fear  of  acting  unnecessarily,  remain 
inactive  under  accidents  or  sufferings  which  it  would  be  easy  to 
prevent  or  alleviate  by  a  skilful  maneuvre.  Whilst  the  membranes 
continue  unruptured,  all  we  ought  to  do  is  to  restore  the  womb  as 
far  as  possible  to  its  natural  attitude,  either  by  pushing  it  with  the 
hand  into  the  axis  of  the  strait,  or  by  causing  the  woman  to  assume 
such  or  such  an  attitude,  according  to  circumstances.  But  if,  the 
membranes  being  ruptured,  the  os  uteri,  although  soft,  should  dilate 
with  exceeding  slowness ;  if  the  pains  should  be  directed  with  great 
force  towards  the  reins,  or  the  strength  appear  likely  to  be  exhaust- 
ed ;  or  lastly,  should  any  accident  supervene,  the  accoucheur 
ought  to  wait  no  longer :  he  should  try  to  reach  the  deviated  part 
with  his  fingers,  or  even  with  the  lever,  if  it  be  the  hip  or  sacrum, 
and  restore  it  to  the  centre  of  the  pelvis ;  or  he  may  proceed  at  once 
to  seek  for  the  feet  or  the  knees. 

§.  III.  Positions  of  the  trunk  of  the  body. 

It  is  incontestable  that  the  trunk  sometimes  presents  at  the  supe- 
rior strait  otherwise  than  by  the  head  or  pelvis ;  this  has  been  ad- 
mitted by  practitioners  in  all  ages,  and  has  been  a  thousand  times 
proved  by  observation.  But  is  it  true  that  these  presentations  ex- 
hibit shades  so  various  and  multiplied  as  has  been  asserted  by  the 
authors?  In  the  first  place,  is  it  possible  for  positions  that  are 
frankly  transverse,  to  take  place  either  before  or  after  the  discharge 
of  tlie  liquor  amnii,  when  the  fotus  is  at  full  term  and  well  grown? 
For  that  end  it  would  be  required  that  the  transverse  diameters  of 
the  womb' should  exceed  the  perpendicular;  but  even  should  such 
a  disposition  exist  before  the  commencement  of  labour,  can  we 
conceive  that  it  could  maintain  itself  under  the  contractions  of  the 
gestative  organ  ?  Would  not  those  contractions  necessarily  compel 
the  head  or  the  breech  to  descend  towards  the  os  uteri  ?  Mauriceau, 
Deventer,  Smellie,  Roederer,  &c.  have  given  drawings  representing 
such  positions,  it  is  true ;  but  none  of  them  is  said  to  have  been 
taken  from  nature,  and  a  mere  glance  suffices  to  satisfy  us  that  they 
arc  all  fancy-pieces.  If  the  ideas  of  these  authors  have  in  our  own  day 
been  reproduced,  with  additions,  is  it  not  rather  in  order  to  be  conform- 
able to  the  notions  of  the  ancients  than  from  direct  observation?  Could 


POSITIONS  OF  THE  TRUNK.  415 

Solayres  and  Baudelocque  be  fit  judges  of  a  question  never  precedent- 
ly  agitated,  particularly  as  they  had  such  motives  to  retain  it  as  it  had 
been  laid  down,  in  order  to  magnify  the  importance  of  a  classification 
which  in  a  great  measure  constituted  their  reputation  and  their  glory? 
I  desire  that,  here,  as  well  as  in  the  succeeding  articles,  no  one 
will  misconceive  of  my  intentions,  and  that  I  may  not  be  charged 
with  want  of  reverence  for  so  many  celebrated  names ;  I  merely 
express  my  doubts,  and  do  not  pronounce  judgment ;  but,  were  it 
necessary  to  combat  the  opinion  and  the  arguments  of  those  ac- 
coucheurs, whether  ancient  or  modern,  who  have  admitted  the  ex- 
istence of  transverse  positions,  by  means  of  authorities  not  less 
respectable  than  they  are,  I  would  suggest,  without  any  allusion  to  my 
own  experience,  that  out  of  more  than  forty  thousand  cases  noticed  by 
Madame  Lachapelle,  and  twenty  thousand  mentioned  by  Merri- 
man,  not  one  of  these  presentations  was  observed  ;  finally,  that  M. 
Dubois  and  M.  Duges  reject  them  as  chimerical  or  superfluous. 

953.  Is  it,  then,  demonstrated  that  the  child  may  present  either  of 
its  three  principal  surfaces  at  the  entrance  of  the  pelvis,  and  that 
inchned  positions  of  the  side  have  not  been  mistaken  for  positions 
of  the  dorsal  or  abdominal  surface  ?  A  multitude  of  cases  are  found 
in  books,  which,  if  taken  according  to  the  letter,  would  lead  to  an 
aflSrmative  answer  to  these  questions  ;  but,  upon  analysing  them 
with  some  degree  of  care,  they  are  soon  found  to  be  accompanied 
with  details  not  sufficiently  circumstantial  to  serve  as  incontrovertible 
proof  of  what  their  authors  have  averred  to  be  the  facts.  Accord- 
ing to  Madame  Lachapelle,  positions  of  the  anterior  and  posterior 
regions  never  do  take  place,  and  those  of  the  side  are  the  only  ones 
that  we  can  conceive  of,  except  it  be  in  some  abortions  ;  she  main- 
tains that  positions  of  the  dorsal  surface  would  not  fail,  under  the 
influence  of  the  uterine  contractions,  to  be  soon  transformed  into 
positions  of  the  shoulder,  should  they  not  result  in  being  reduced  to 
some  positions  of  the  head  or  pelvis  ;  that  those  of  the  abdominal 
surface  would  require  a  reversement  of  the  occiput,  of  the  lower 
extremities  and  spine,  incompatible  with  the  life  of  the  foetus.  For 
my  own  part,  I  think  that  the  back  and  the  anterior  surface  of  the 
foetus  may  present  at  the  superior  strait ;  that  these  positions  have 
been  observed  ;  that  proofs  of  them  are  contained  in  the  works  of 
Deventer,  De  la  Motte,  &-c.,  but  that  they  are  rare,  and  difier  so 
little  from  the  positions  of  the  side,  as  to  require  only  very  slight  mo- 
difications in  the  maneuvres  appropriate  to  these  latter. 

954.  Baudelocque  admits,  further,  that  in  the  posterior  surface 
we  should  distinguish  the  occiput,  the  nucha,  the  back,  the  loins. 


416  DYSTOCIA. 

and  the  posterior  surface  of  the  pelvis  ;  and  that  the  anterior  and 
lateral  surfaces  require  the  same  subdiv-  ions.  But  while  we  ad- 
mit that  the  fojtus  may,  indeed,  present  by  these  different  points,  it 
would  be,  nevertheless,  useless  to  adopt  such  numerous  positions, 
for  they  are  of  no  practical  application,  overload  the  memory  with- 
out any  object,  and  only  serve  to  discourage  the  student. 

955.  The  simple  good  sense  and  observations  of  Denman  and 
Madame  Lacbapelle,  prove  that  the  nucha  cannot  maintain  itself  at 
the  superior  strait,  that  it  would  soon  give  place  to  the  head  or 
shoulder,  and  that  positions  of  the  hip  or  loins  could  not  fail  to  be 
soon  transformed  into  a  direct  or  inclined  position  of  the  breech. 

It  is,  then,  evident  that  a  position  of  the  abdomen  has  often  been 
supposed  present,  when,  in  reality,  it  was  only  an  inchned  position 
of  the  breech,  feet,  or  knees,  complicated  with  one  of  the  arm,  or 
with  a  premature  escape  of  the  umbilical  cord.  Madame  Lacba- 
pelle thinks  that  the  throat  would  not,  under  the  contractions  of  the 
womb,  be  long  permitted  to  remain  at  the  orifice,  for  the  pains 
would  bring  the  face  there  far  more  easily.  I  am  in  possession  of 
no  facts  to  militate  against  the  opinion  of  this  author,  and  know 
that  on  this  point  many  practitioners  might  have  been  deceived  by 
the  touch  ;  however,  I  can  conceive  that,  where  the  occiput  is 
very  much  reversed  backwards,  the  chin  may  lodge  upon  some 
part  of  the  pelvic  circle,  and  compel  the  anterior  part  of  the 
breast  and  neck  to  fix  itself  at  the  orifice,  while  the  breech,  although 
retaining  its  natural  relations  to  the  abdominal  members,  remains  at 
the  fundus  of  the  uterus.  In  order,  therefore,  to  avoid  the  reproach 
of  abandoning  one  extreme  for  the  purpose  of  falling  into  another, 
I  shall  admit  the  positions  of  the  back,  and  of  Uie  uuterior  face  of 
the  tiiorax,  as  at  least  possible  occurrences. 

956.  As  to  presentations  of  the  side,  they  are  too  frequently  met 
with,  for  their  existence  ever  to  have  been  tlie  subject  of  a  doubt ; 
but  the  classification  of  Baudelocque,  although  recently  brought 
forward  again  in  America  by  Dr  Dewees,  one  of  tiie  most  dis- 
tinguisiicd  accoucheurs  in  the  now  world,  here  requires  the  same 
reform  as  in  the  anterior  and  posterior  surfaces.  The  sides  of  tiic 
neck  form  too  deep  a  notch  betwixt  the  slioulders  and  head,  not  to 
yield  a  passage  to  one  of  these  parts  ;  the  side  of  the  chest  being 
less  round,  and  particularly  not  so  smooth  as  the  point  of  the 
slioulder,  could. not  l)inder  the  latter  from  engaging  in  the  os  uteri ; 
lastly,  the  flanks  would  soon  bring  about  a  hip  or  breech  position. 

967.  Causes.  Inclinations  of  the  womb  or  of  the  straits  of  the 
pelvis,  sudden  and  irregular  movements  of  the  fcctus,  certain  atti- 


SPONTANEOUS  ETVOLUTION.  417 

tudes  of  the  woman  long  persisted  in,  are  the  principal  causes  to 
which,  in  the  present  st-'te  of  our  knowledge,  we  may  attribute  the 
bad  positions  of  the  foetus. 

958.  Hippocrates  was  the  first  one  to  say  that  the  foetus  in  utero 
was  in  some  degree  situated  similarly  to  an  olive  or  a  cork  in  a  long 
necked  bottle  ;  that  in  order  to  escape  from  the  genital  organs,  it 
must  present  one  of  the  ends  of  its  long  diameter  ;  and  that  any 
other  presentation  was  dangerous,  rendered  delivery  impossible,  and 
imperiously  demanded  the  assistance  of  art. 

This  doctrine,  which  has  been  republished  by  all  the  authors  since 
the  father  of  medicine,  and  against  which  no  one  has  made  any  ob- 
jections even  in  our  own  days,  is,  notwithstanding,  not  free  from  all 
doubt. 

The  comparison  instituted  by  Hippocrates  is  not  correct,  except 
in  so  far  as  the  foetus  remains  in  a  normal  position  ;  in  the  other 
cases,  the  child  represents  neither  an  oval  nor  a  cone  placed  trans- 
versely or  obliquely  :  whilst  the  head  turns  on  one  of  its  sides,  be- 
hind, or  in  front,  whilst  the  shoulder,  the  breast,  or  the  back  tend 
to  engage,  the  remainder  of  the  trunk  continues,  notwithstanding, 
in  due  relation  with  the  vertical  axis  of  the  uterus,  whenever  the  con- 
tractions are  somewhat  energetic  ;  and  thenceforth  the  foetus  is  in 
no  respect  like  a  cork  that  presents  crosswise  in  the  throat  of  a  vial. 

969.  No  doubt  the  hand  of  the  accoucheur  is  often  necessary,  and 
even  indispensable,  when  it  is  neither  the  head  nor  pelvis  that  pre- 
sent ;  but  it  is  also  certain  that  the  organism  alone  would,  in  many 
cases,  triumph  over  this  obstacle  were  the  labour  left  to  itself.  Peo- 
ple have  in  practice  reasoned  as  if  the  positions  of  the  trunk,  when 
once  determined,  could  never  change.  But  daily  observation  proves 
that  the  different  points  of  the  foetus,  though  very  remote  from  each 
other,  may,  during  a  labour,  present  alternately  at  the  orifice  ;  that 
positions  of  the  back  or  shoulder  may  be  converted  into  positions  of 
the  head  or  breast;  that  positions  in  appearance  the  most  unfavour- 
able might  sometimes  be  replaced  by  normal  positions,  were  all  ac- 
coucheurs sufficiently  well  informed  to  know  how  to  wait. 

960.  Those  passive  movements  undergone  by  the  fcetus  in  utero^ 
which  Denman  has  mentioned  under  the  title  of  spontaneous  evolu- 
tion^ and  which  M.  Murat  calls  spontaneous  version,  have  been 
carefully  observed  by  Madame  Lachapelle,  and  noticed  by  Garth- 
shore,  Martineau,  &c.  Neither  were  the  ancients  wholly  unaware 
of  them,  since  they  advise  that,  for  the  purpose  of  bringing  the  head 
back  to  the  strait,  the  woman  should  be  shook  or  assume  certain 
positions.  Most  modern  authors  have  also  remarked  them,  since 
they  have  laid  it  down  as  an  established  rule,  that  the  position  of  the 
3C 


418  DYSTOCIA. 

child,  while  still  enclosed  in  the  membranes,  is  so  variable,  that,  in 
order  to  fix  it,  it  becomes  necessary  to  rupture  the  ovum,  choosing 
a  moment  when  the  head  corresponds  to  the  centre  of  the  pelvis  ; 
but  upon  this,  as  upon  all  those  phenomena  that  have  not  been  the 
objects  of  special  study  and  attention,  little  thought  has  been  given 
to  the  practical  consequences  that  might  follow  it. 

961.  Although  the  spontaneous  evolution  takes  place  most  fre- 
quently where  there  is  a  superabundant  quantity  of  liquor  amnii, 
where  the  foetus  is  not  large,  where  the  womb  is  very  much  incHned, 
or  where  the  pelvis  is  badly  formed,  it  may,  nevertheless,  be  some- 
times observed  in  the  directly  contrary  conditions.  Although  it 
more  commonly  and  easily  takes  place  before  the  rupture  of  the 
membranes,  it  is,  notwithstanding,  found  to  occur  after  the  evacua- 
tion of  the  waters  :  a  young  woman,  in  her  second  pregnancy,  was 
admitted  into  the  hospital  of  the  Ecole  de  Medecine,  at  ten  A.M. 
in  the  month  of  August  1825.  The  os  uteri  was  then  but  little 
dilated ;  nevertheless,  I  discovered  that  the  shoulder  presented  in 
the  second  position.  The  waters  were  not  discharged  until  three 
o'clock  in  the  afternoon  ;  four  students,  who  were  already  well  ad- 
vanced, touched  and  recognised  the  presence  of  the  shoulder,  as  I 
had  done.  I  did  not  wish  to  bring  down  the  feet ;  the  pains  were 
neither  very  strong  nor  very  frequent,  and  I  had  some  confidence  in 
the  assertions  of  Denman.  At  eight  o'clock  the  shoulder  was  found 
to  be  evidently  moved  towards  the  left  iliac  fossa,  and  I  could  easily 
feel  the  ear  to  the  right.  At  eleven  o'clock  the  temple  was  nearly  in 
the  centre  of  the  orifice  :  the  energy  of  the  contractions  was  greater, 
and  the  os  uteri  completely  eflaced.  At  midnight  the  occiput  came 
down,  and  in  the  space  of  an  hour  the  child  was  expelled  in  the 
right  occipito-acetabular  position. 

962.  It  appears  to  me  that  the  explanation  of  spontaneous  evolu- 
tion is  an  easy  matter  :  the  head  of  the  fcetus,  which  is  its  most  solid, 
voluminous,  and  regularly  rounded  part,  and  on  that  account  its 
most  slippery  portion,  naturally  tends  towards  one  of  the  two  ex- 
tremities of  the  great  diameter  of  the  uterus,  and  towards  the  cavity 
of  the  pelvis ;  if,  under  the  influence  of  any  cause,  it  has  assumed 
any  other  position,  it  is  very  natural  that  when  pressed  by  the  organ 
in  which  it  is  enclosed,  it  should  gradually,  and  without  much  diffi- 
culty, reassume  the  situation  it  occupies  when  in  its  natural  circum- 
stances. When  the  womb  contracts,  if  the  fcctal  ovoid  is  well  situ- 
ated, it  becomes  compressed  equally  in  every  direction,  but  if,  on 
the  contrary,  it  is  in  a  deviated  position,  its  extremities  support, 
almost  alone,  the  whole  effort  of  the  contraction,  and  but  for  the 
shoulder,  which  is  from  its  salient  form  apt  to  be  arrested  at  the 


SPONTANEOUS  EVOLUTION.  41 9 

strait,  either  the  head  or  the  breech  would  be  almost  always  brought 
to  the  strait. 

For  this  consequence  to  fail  taking  place,  which  is  almost  impos- 
sible, the  middle  of  the  child's  body  ought  to  correspond  exactly  to 
the  centre  of  the  pelvis,  so  that,  of  its  two  extremities,  one  should 
not  be  more  disposed  than  the  other  to  slide  up  towards  the  fundus, 
or  down  to  the  orifice  of  the  womb  ;  besides,  the  difference  of  the 
shape  of  the  hejid  and  breech  would  render  this  equilibrium  extremely 
difficult.  There  is  nothing  very  extraordinary,  therefore,  in  the  evo- 
lution or  spontaneous  version  of  the  child  ;  it  is  quite  a  natural  phe- 
nomenon, easily  explained  by  the  action  of  the  womb  and  its  rela- 
tions to  the  form  of  the  ovum  and  foetus.  The  mechanism  of  this 
evolution  explains  why  the  anterior  and  posterior  positions  of  the 
trunk  are  so  rare,  and  shoulder  cases  so  common.  If,  when  some 
point  on  the  dorsal  or  abdominal  surface  of  the  child  offers  at  the 
strait,  the  head  or  the  pelvis  are  too  far  removed  from  it  to  be 
brought  back  again,  the  pains  never  fail  to  act  with  a  certain  degree 
of  force  upon  the  two  extremities  of  the  bis-acrimonial  diameter, 
which  then  becomes  inclined,  and  one  of  the  shoulders  is  soon  com- 
pelled to  engage  in  the  open  part  of  the  strait. 

963.  To  conclude,  from  the  above  details  I  think  it  follows : 

1st.  That  all  those  positions  of  the  trunk  that  can  not  be  referred 
to  those  of  the  shoulder,  the  back,  or  the  anterior  part  of  the  thorax, 
ought  to  be  classed  among  the  inclined  positions  of  the  head.  2d.  That 
shoulder  presentations  are,  so  to  speak,  the  only  ones  that  require 
particular  attention,  inasmuch  as  all  others  are  naturally  reduced  to 
them.  3d.  That  the  child  is  never  situated  completely  crosswise  in 
the  womb,  and  that  the  most  untoward  positions  may  sometimes  be 
expected  to  be  reduced  to  those  that  are  most  favourable.  4th. 
That  there  are  a  good  many  cases,  in  which  the  interference  of  art 
is  any  thing  but  indispensable,  although  the  foetus  may  present  by 
neither  end  of  its  great  diameter. 

964.  The  indications  to  be  fulfilled  in  cases  of  faulty  position  of 
the  child  necessarily  vary  according  to  a  great  variety  of  circum- 
stances. Until  the  waters  are  discharged,  nothing  is  to  be  done. 
We  should  wait  for  the  dilatation  of  the  os  uteri ;  if  the  uterus  is 
obliquely  situated  we  must  endeavour  to  restore  it  to  .its  natural  at- 
titude ;  should  the  head  project  over  the  hypogastric  notch  of  the 
pelvis,  it  should  be  pushed  backwards  over  the  edge  of  the  strait ; 
when  the  foetus  is  so  movable  that  the  head,  the  shoulder,  or  some 
other  part  come  to  present  successively  at  the  orifice,  it  is  proper,  as 
has  been  said,  to  rupture  the  membranes  without  waiting  too  long. 


420  DYSTOCIA. 

and  choosing  the  exact  moment  when  the  head  happens  to  be  over 
the  strait. 

But  if  the  OS  uteri  is  already  sufficiently  dilated,  if  the  membranes 
are  already  ruptured  or  on  the  point  of  giving  way,  it  is  important 
to  decide  at  once,  whether  or  not  the  hand  is  to  be  carried  into  the 
womb.  Denman  tells  us  that  we  may  dispense  with  doing  so  in  a 
majority  of  cases,  seeing  that  the  womb,  most  generally,  will  bring 
about  the  spontaneous  evolution,  and  that  if  the  child  should  really 
come  down  doubled,  its  escape  would  not,  on  that  account,  be 
wholly  impossible.  The  French  accoucheurs  think,  on  the  contrary, 
that  we  ought  to  act  immediately  in  all  cases;  for,  say  they,  the 
longer  we  wait  the  more  will  the  womb  contract,  and  the  more  dif- 
ficult will  it  become  to  enter  it  and  effect  the  turning. 

The  conduct  of  Denman  in  this  case  does  not  appear  to  me  to  be 
of  the  very  wisest :  by  imitating  him,  it  is  true,  some  foetuses  that 
we  deliver  by  the  feet  might  come  away  spontaneously,  but  many 
more  of  them  would  fall  victims  to  such  an  expectant  mode  of  prac- 
tice, and  which  might  be  saved  by  operating  in  good  time.  As  to 
delivering  the  fcetus  double,  it  is  manifest  that  it  must  be  very  diffi- 
cult, that  it  will  most  generally  not  take  place  at  all,  and  that  the 
woman  will  be  exhausted  with  useless  effijrts,  and  may  lose  her  life  ; 
that  even  under  the  most  favourable  conditions  of  this  kind,  the 
child  generally  dies  long  before  it  is  born,  at  least  if  we  may  judge 
from  Denman's  own  cases,  since  out  of  thirty  of  them  only  one  was 
born  living. 

Thus,  although  spontaneous  evolution  may  take  place,  and  rigo- 
rously speaking,  some  women  may  be  delivered  without  it,  it  is 
nevertheless  more  conformable  to  the  dictates  of  prudence  and  hu- 
manity to  turn  the  child,  or  apply  the  forceps.  To  this  rule  an  ex- 
ception should  be  made  of  those  cases  where  the  shoulder  is  not 
fully  engaged,  those  where  the  vertex  or  the  pelvis  is  near  enough 
to  the  orifice  to  allow  us  to  rely  upon  a  fortunate  transmutation, 
and  lastly,  those  where  the  introduction  of  the  hand  is  so  difficult 
that  it  would  not  be  more  dangerous  to  wait  than  to  proceed  at 
once  to  the  operation. 


% 


^■, 


TABLE  III. 
Anormal  Presentations  of  the  Foetus. — Tokological  Pperqiions. 


AUTHOHS. 


Boer. 

Bland 

Merriman.       .     .     . 
Madame  Boivin. 
Madame  Lachapelle. 
M.  Nagele.     .     .     , 
M.  Negele.     .     .     . ' 


Total. 


e  -e 


6,555 

1,897 

1,800 

20,517 

22,243 

415 

1,296 


54,723 


126 
S6 
42 
363 
492 
15 
61 


68 

18 

u 

23 
234 
203 


58 

5 

4 

74 

103 

4 


96 
118 


18 


1135  546   248      13   234   287 


39 

9 

29 

218 

174 

3 

19 


491 


60 


421 


CHAPTER  VI. 

Of  Obstetric  Operations. 

ARTICLE  I. 
Of  Turning. 

965.  The  word  turning  is,  in  tokology,  applied  to  the  act  of 
turning  the  child  with  the  hand,  and  bringing  one  of  the  extremities 
of  its  great  diameter  to4he  superior  strait.  There  are  two  kinds 
of  turning ;  in  one  the  head,  and  the  other  the  feet  are  brought 
down  first. 

Hippocrates  has  a  few  words  upon  the  subject  of  turning,  but 
only  of  version  by  the  head.  Celsus  advises  that  the  feet  should  be 
drawn  down  where  it  is  too  difficult  to  get  hold  of  the  head,  but  he 
dares  not  perform  this  maneuvre  except  when  the  child  is  dead. 
Aetius  and  Paul  of  Egina  are  the  only  ones  among  the  ancients 
who  have  applied  the  idea  of  Celsus  to  the  living  foetus  ;  although 
it  is  mentioned  in  Wolf's  Collection,  and  though  Franco  and  Pare 
have  treated  of  it  as  a  common  practice,  we  must  come  down  as 
late  as  the  time  of  Guillemeau  before  we  can  obtain  any  circum- 
stantial details  concerning  it.  Previously  to  the  time  of  this  last 
mentioned  author,  all  those  practitioners  who  were  either  ignorant 
of,  or  refused  to  adopt  the  operation  of  turning  by  the  feet,  Were 
reduced  to  the  necessity  of  bringing  away  the  child  piece-meal 
from  the  womb,  after  having  allowed  it  to  perish,  or  else  to  extract 
it  with  the  crotchet  or  some  other  instrument  in  all  cases  where 
they  thought  it  not  possible  to  bring  the  head  to  the  strait.  Besides, 
until  then  there  never  had  been  any  question  about  bringing  down 
the  feet,  except  as  a  remedy  for  faulty  positions,  as  positions  of  the 
body,  for  example.  It  is  only  since  Guillemeau's  day  that  it  has 
been  recommended  to  bring  down  the  feet  and  make  a  complete 
version  and  delivery  of  the  child,  in  cases  attended  with  some  acci- 
dent, the  head  being  already  at  the  strait. 


422  TURNING.  i 

SECTION  1. 

Of  Turning  in  general. 

The  necessity  of  acting  with  the  hand  to  change  the  position  of 
the  foetus  or  assist  in  its  expulsion  having  been  clearly  ascertained, 
it  should  be  communicated  to  the  relatives  or  friends  of  the  woman, 
and  they  should  be  informed  of  the  dangers  to  which  the  child  is 
exposed.  Provided  the  case  be  at  all  doubtful,  or  if  the  family  have 
not  implicit  confidence  in  him  ;  if  his  age,  or  above  all  his  reputation 
do  not  place  him  beyond  the  reach  of  the  envenomed  shafts  of  envy, 
it  is  well  for  the  safety  of  all  parties,  that  the  accoucheur  should 
request  a  consultation  with  one  or  more  of  his  brethren,  best  known 
by  their  experience  and  knowledge. 

966.  As  to  the  woman  herself,  she  ought  to  be  informed  of  the 
advantages  of  the  operation,  and  of  the  evils  of  retarding  it  or  of  not 
performing  it ;  but  it  is  important  that  she  should  be  kept  in  igno- 
rance of  the  risks  the  foetus  is  about  to  run,  and  the  sufferings  to 
which  she  is  exposed  herself.  These  precautions  being  taken,  we 
should  next  think  of  what  period  of  the  labour  we  should  choose  for 
the  operation,  of  the  position  most  favourable  for  the  woman  and 
for  the  accoucheur,  then  of  the  position  of  the  child,  and  lastly, 
determine  which  hand  should  be  introduced. 

967.  The  time  for  acting.  As  long  as  the  membranes  remain 
whole,  and  the  orifice  undilated,  we  may  wait :  if  the  labour  is  dif- 
ficult only  in  consequence  of  the  faulty  position  of  the  child,  and 
the  woman  is  in  danger,  it  suffices  that  the  orifice  be  soft  and  dilata- 
ble ;  we  may  operate.  In  all  cases  where  the  membranes  are  rup- 
tured, there  is  not  an  instant  to  lose  ;  however,  where  the  womb  has 
been  for  a  long  time  contracted  ;  where  there  are  great  irritation, 
heat,  fever,  or  any  symptoms  of  inflammation,  these  epiphenomena 
ought  to  be  first  combated  by  bleeding,  baths,  sedatives,  ointment 
of  belladonna,  &c.  according  to  circumstances. 

Upon  the  whole,  the  most  favourable  moment  for  turning  is  just 
when  the  membranes  are  whole  and  the  os  uteri  completely  dilated. 
This  period  ought,  therefore,  always  to  be  chosen  if  possible,  and  if 
there  be  no  counter  indication  present. 

968.  Position  of  the  woman.  Should  it  be  necessary  only  to 
bring  back  the  head  or  buttocks,  in  case  of  deviated  position  of  those 
parts,  to  the  superior  strait,  we  might  indeed  leave  the  woman  upon 
her  common  bed  ;  or  in  the  situation  she  had  occupied  on  her  little 


TURNING.  423 

bed  during  the  pains ;  but  whenever  it  becomes  necessary  to  seek 
after  the  head  or  feet  at  some  distance  from  the  vulva,  we  ought  to 
act  differently ;  however,  the  essential  point  on  this  subject  is  that 
the  vulva  and  perineum  shall  be  completely  at  liberty,  and  that 
nothing  about  the  pelvis  shall  be  left  to  interfere  with  the  move- 
ments of  the  accoucheur,  and  that  the  muscles  shall  not  require  to 
be  put  in  tension  for  the  support  of  some  other  parts  of  the  body. 
Thus,  she  may  be  placed  on  her  side,  conformably  to  the  precepts 
of  the  English  and  American  practitioners  :  on  the  edge  or  foot  pf 
the  bed  ;  on  the  knees  of  some  stong  person  ;  on  a  chair,  a  settee, 
a  table,  or  any  piece  of  furniture  suitably  prepared  for  her.  Upon 
the  whole,  her  attitude  ought  to  be  like  that  of  a  patient  during  the 
operation  of  lithotomy. 

969.  At  the  Maternite  at  Paris,  and  the  Strasburg  Hospital,  one 
side  of  the  lying-in-bed  is  placed  against  a  wall ;  as  soon  as  an  ope- 
ration becomes  necessary,  the  woman  places  herself  crosswise  upon 
h,  with  pillows  under  her  head  and  shoulders,  towards  the  wall ; 
the  sacrum  rests  upon  the  free  edge  of  the  bed ;  an  assistant  is 
placed  on  the  outside  of  each  leg,  and  charged  with  the  duty  of 
keeping  them  separate,  and  the  legs  and  thighs  flexed,  while  a  third 
is  prepared  to  hand  any  thing  that  may  be  wanted  during  the  opera- 
tion. If  they  can  be  disposed  of,  other  assistants  secure  the  pelvis, 
and  prevent  those  disorderly  movements  which  the  sufferings  of  the 
woman  sometimes  deprive  them  of  the  power  of  controlling. 

970.  The  same  conduct  may  be  followed  in  private  practice,  but 
it  appears  to  me  better  to  slip  the  mattress  down  so  that  the  folded 
edge  may  correspond  to  the  foot  of  the  sacking- bottom.  The  wo- 
man is  then  in  exactly  the  same  condition  as  before,  and  the  assis- 
tants can  more  easily  move  round  about  her.  It  should  be  observ- 
ed, that  many  women  are  so  courageous  that  it  is  not  necessary  to 
support  either  the  legs  or  the  head,  and  indeed,  two  chairs  or  two 
stools,  fixed  so  as  to  support  the  feet,  might  serve  instead  of  assis- 
tants to  hold  her  legs,  if  assistants  are  wanting. 

There  is  no  fixed  rule  as  to  the  height  of  the  bed  ;  but  it  is  well 
to  pay  some  regard  to  the  stature  of  the  accoucheur,  the  degree  of 
inclination  of  the  axes  of  the  straits,  and  perhaps  also  to  the  stage 
of  the  labour. 

971.  Position  of  the  accoucheur.  If  the  bed  be  a  low  one,  the 
accoucheur  may  sit  down  or  kneel  upon  the  floor.  Nevertheless,  a 
standing  posture  is  unquestionably  the  best,  and  whenever  there  is 
a  necessity  for  using  much  power  it  should  be  preferred.  The  pre- 
cept of  Levret  on  this  subject  has  long  been  forgot,  which  was  thus  : 
'"'•  the  accoucheur  should  stand  up,  with  his  legs  separated  at  air 


424  TURNING. 

angle  of  forty-five  degrees,  one  foot  being  placed  forward  and  the 
other  backwards  ;  that  he  should  have  the  spine  bowed,  and  lean 
with  the  hand  that  he  does  not  operate  with  upon  some  soUd  sub- 
stance." 

All  this,  says  Roussel,  may  be  called  mechanics  and  geometry  by 
an  operator  who  wishes  to  shed  lustre  on  his  art ;  but  certain  it  is, 
that  a  simple  midwife,  by  relying  upon  her  native  dexterity,  absolving 
herself  from  the  constraints  of  a  prescribed  position,  and  executing 
all  the  motions  that  may  be  required  by  circumstances  rather  than 
those  demanded  by  the  rule,  will  operate  better  than  an  accoucheur, 
no  matter  how  gravely  he  may  straddle  his  forty-five  degrees. 

972.  Taking  off  the  coat,  rolling  up  the  sleeves,  and  putting  on 
an  apron  has  seemed  too  grotesque  to  many  moderns,  who  think 
that  the  women  might  be  frightened  by  so  many  preparations,  and 
they  ought  therefore  to  be  dispensed  with  :  people  may  declaim  after 
this  sort  as  much  as  they  please  in  the  study,  but  by  the  lying-in 
bed  it  is  otherwise. 

In  fact  it  is  not  merely  for  fear  of  spoiling  it  that  the  accoucheur 
ought  to  take  off"  his  coat,  but  because,  unless  he  does  so,  the  move- 
ments of  his  arms  would  not  be  free  enough  to  permit  him  to  ma- 
neuvre  conveniently,  and  penetrate  to  the  fundus  of  the  womb.  As 
to  the  apron,  it  may  doubtless  be  dispensed  with :  but  what  harm 
can  it  do,  and  why  is  it  more  frightful  here  than  in  a  surgeon  making 
his  visits,  or  preparing  for  an  operation  ? 

Some  cloths  to  put  under  the  feet,  some  napkins  to  wipe  his 
hands  and  arms  when  they  become  soiled,  warm  water,  Cologne- 
water,  some  vinegar,  and  a  little  good  wine,  in  case  the  woman 
should  be  likely  to  be  ill,  are  also  necessary  previously  to  com- 
mencing the  operation.  Moreover,  the  condition  of  the  foetus  must 
be  attended  to,  its  position  ascertained,  and  the  hand  to  be  intro- 
duced to  be  decided  upon. 

973.  The  christening  or  provisional  baptism  is  only  applicable  to 
a  living  child,  and  that,  provided  it  be  not  a  monster.  Where  there  is 
ground  to  fear  that  it  is  dead,  we  should  say,  "  Child,  1  baptise  thee, 
&,c.  if  thou  art  living  ;"  and  where  there  is  reason  to  suspect  it  of 
being  a  monster,  we  substitute  for  if  thou  art  living,  the  wor«  if 
thou  art  worthy  of  being  baptised.  In  order  to  baptise,  some  part 
of  the  naked  surface  of  the  child  should  be  touched,  if  not  with  the 
fingers,  at  least  with  the  water  of  christening,  which  it  is  sometimes 
necessary  to  inject  to  a  considerable  distance. 

This  precaution,  which,  as  is  manifest,  belongs  to  the  dogmas  of 
religion,  ought  never  to  be  neglected  with  persons  who  make  of  it 
an  article  of  faith.     Whatever  be  his  personal  behef,  the  physician 


PROLAPSED  CORD,  ANEURISM,  ASTHMA.  435 

ought  to  respect  the  opinions  of  the  families  he  attends,  \vbcthcr 
they  agree  with  his  own  or  not ;  and  to  me  nothing  seems  more 
blameworthy  than  those  pragmatical  practitioners  who,  under  pre- 
tence of  reforming  consciences,  openly  revolt  against  every  custom 
that  does  not  square  with  their  own  way  of  thinking. 

974.  To  ascertain  the  position  of  the  fxtus.  The  positions  of 
the  head,  the  feet,  the  knees,  and  the  breast,  having  been  charac-; 
terized  in  the  article  on  eutocia,  I  have  now  to  attend  only  to  those 
of  the  trunk. 

Presentations  of  the  shoulder,  whether  frank  or  inclined,  will,  if 
the  arm  have  not  come  down,  be  ascertained  by  the  rounded  form 
of  the  tumour  in  the  orifice,  by  the  presence  of  the  clavicle,  the 
ribs,  the  scapula,  and  one  side  of  the  neck. 

When  the  arm  escapes  first,  it  not  only  indicates  that  the  shoul- 
der is  at  the  superior  strait,  but  it  also  teaches  us  to  which  side  of 
the  pelvis  the  vei-lex  and  also  the  face  are  turned.  The  thumb  cor- 
responds to  the  summit  of  the  head,  while  the  palm  of  the  hand  an- 
swers to  the  abdominal  surface.  However,  it  is  important  to  know, 
that,  instead  of  being  in  a  state  of  supination,  or  even  of  slight  pro- 
nation, the  hand  and  the  whole  limb  may  be  twisted  in  a  contrary 
direction,  and  especially  into  forced  pronation  ;  so  that  previously 
to  giving  a  definitive  judgment,  it  is  best  to  slip  some  of  the  fingers 
into  the  vagina,  along  the  cubital  edge  of  the  arm,  as  far  as  the  arm- 
pit, so  as  to  make  sure  of  its  relative  situation. 

If  the  back  should  stop  at  the  centre  of  the  strait,  the  range  of 
the  vertebral  spines  and  the  ribs  would  sufiice  to  point  it  out.  The 
absence  of  ribs  in  the  lumbar  region,  or  on  the  one  hand  the  liips, 
and  on  the  other  the  scapula;  and  back  part  of  the  neck,  might 
serve  to  show  which  way  the  head  is  directed. 

The  sternum,  the  ribs  and  clavicles,  above  which  we  can  also 
sometimes  feel  the  front  of  the  neck,  indicate  presentations  of  the 
anterior  face  of  the  thorax. 

Where  the  os  uteri  is  largely  dilated  and  the  membranes  ruptured, 
and  the  presenting  part  is  not  too  high  up  in  the  pelvis,  and  has  not 
had  time  to  swell  and  alter  its  shape  under  the  influence  of  the  uje- 
rine  contractions;  it  is  in  general  pretty  easy  to  distinguish  the  differ- 
ent positions  of  the.  trunk  from  each  other;  it  is  at  least  always 
possible  to  avoid  confounding  them  with  those  of  the  head  or  pelvis; 
but  in  the  contrary  circumstances  the  most  consummate  experience 
is  sometimes  deceived,  and  it  is  often  inijjossible  to  establish  a'cer- 
tain  diagnosis  until  after  having  r  hand  into  the  womb. 

975.  Choice  of'  the  hand.  \\  1,  oag  of  waters  is  still  un- 
broken, or  the  foetus  retains  a  coh'siderable  degree  of  mobility,  it  i> 

3D 


426  DYSTOCIA.         ^0lftf»^ 

useless  to  delay  about  the  choice  of  a  hand  to  operate  witlr:  the  one 
that  is  most  easily  used  is  to  be  introduced,  or  the  one  which  habi- 
tually brings  down  the  child  in  the  least  unfavourable  position  ; 
where  the  position  has  not  been  ascertained,  or  is  merely  a  matter 
of  doubt,  the  practitioner  ought  to  act  in  the  same  manner,  or  may 
make  use  of  the  hand  commonly  employed  in  operating  for  those 
positions  most  frequently  met  with  ;  if,  however,  there  should  occur 
any  dilliculty  after  reaching  the  womb,  it  is  best  to  withdraw  it  and 
introduce  the  other  hand. 

In  cases  where  the  presentation  is  well  determined,  we  may 
know  at  once  which  hand  is  most  favourable  to  the  success  of  the 
operation  ;  this  is  moreover  liable  to  vary  according  to  the  kind  of 
maneuvre  about  to  be  executed,  or  which  it  is  indispensably  neces- 
sary to  attempt. 

976.  For  those  inclined  positions  of  the  head  and  breech  which 
do  not  require  immediate  version  by  the  feet,  the  left  hand  ought  to 
be  preferred.  Whenever  the  deviated  parts  correspond  to  some 
portion  of  the  right  half  of  the  pelvis ;  the  right  hand,  on  the  con- 
trary, in  the  opposite  deviations,  and  either  of  them,  indifferently,  if 
the  deviation  takes  place  directly  front  or  back.  The  cephalic  ver- 
sion ought  to  be  subjected  to  the  same  rule  of  practice. 
,  977.  For  the  feet,  knees,  or  breech,  those  positions  in  which  the 
posterior  surface  of  the  fa3tus  looks  towards  the  left  side  of  the  pel- 
vis, are  best  operated  on  with  the  left  hand,  and  the  inverse  posi- 
tions with  the  right  hand,  although  it  may  be  most  frequently  in  our 
power  to  do  just  the  contrary  if  we  please.    ■  , 

978.  When  the  vertex  presents  first  and  we  have  to  bring  down  the 
feet,  the  left  hand  is  most  suitable,  in  left-occipito-pelvic  positions, 
that  is,  the  first  and  fifth  of  Baudelocque.  (First  and  fourth  of  MM. 
Maygrier,  Capuron,  Dugos,  &,c  ;  first,  fourth,  and  fifth  of  Madame 
Lachapelle  ;  left-occipito-acetabular,  and  right  fronto-acetabular  of 
M.  Gardien.)  The  right  hand,  rigorously  speaking,  is  only  for  the  dia- 
metrically ojjposite  positions  ;  but  as  it  terminates  a  labour  in  the 
first  position  of  the  leet,  as  it  is  more  handy  from  customary  use, 
and  as  it  maneuvres  as  weii  as  the  other  in  median  positions,  it 
ought  to  be  selected  for  all  the  right  and  antero-posterior  positions. 

979.  In  shoulder  presentations  we  may  lay  it  down  as  a  general 
rule,  that  the  left  side  requires  the  use  of  the  left  hand,  and  that 
the  right  hand  siiould  operate  in  the  positions  of  the  right  shoulder. 

980.  Lastly,-  we  ought  to  make  use  of  the  right  hand  in  presen- 
tations of  the  sternum,  or  back,  whenever  the  head  is  not  turned  to 
the  left,  and  of  the  left  hand  in  the  opposite  casQ.      .     . 

981.  Theso  general  rules  appear  tcme  to  be  simple,  applicable 


TURNING,  CHOICE  OF  THE  HEAD.  427 

to  all  cases,  and  eas)rto  be  understood.  Baudelocque,  Madame 
Lachapellc,  M.  Dug^s,  M.  Desormcaux,  and  very  recently,  M. 
Major  of  Lausann4^also,  have  advised  us  to  introduce  that  hand 
which,  when  in  a  state  of  semi-pronation,  will  have  the  palm  turned 
tttwards  the  front  of  the  child,  and  the  fingers  towards  its  lower  ex- 
tremities ;  but  this  rule  is  too  vague,  and  liable  to  too  many  excep- 
tions for  it  to  be  used  in  practice.  It  is  not  perfectly  exact,  either 
in  positions  of  the  pelvis,  or  those  of  the'  back  or  shoulder,  and  in 
positions  of  the  head  and  sternum  it  is  only  suitable  in  the  first  stage 
of  the  operation. 

Those  who  have  recommended  the  introduction  of  the  hand  that 
is  naturally  turned  towards  the  side  of  the  pelvis  where  the  feet  are 
situated,  did  not  observe  that  it  most  commonly  happens,  even  in 
shoulder  positions,  that  the  feet  remain  up  towards  the  fundas  of  the 
womb,  without  being  sensibly  inclined  to  one  side  more  than  to  the 
other ;  neither  did  they  remark  that  precisely  the  contrary  rule  is 
followed  where  the  pelvis  presents  first. 

When  M.  Gardien  says  that  the  right  hand  is  required  in  all 
those  cases  where  the  feet  are  to  be  brought  down  in  the  first,  and 
the  left  where  they  are  to  be  brought  down  in  the  second  position, 
he  has  approached  nearer  to  the  truth,  although  his  assertion  is  not 
correct  either,  except  forpositions  of  the  head  and  trunk  ;  but  he  has 
rather  expressed  a  fact  than  endeavoured  to  lay  down  a  rule,  which, 
however,  naturally  follows  from  the  principles  that  I  have  indicated 
above. 

Dr  Breen  advises  us  always  to  use  the  left  hand,  inasmuch,  says 
he,  as  the  right  is  infinitely  more  commodious  in  assisting  the  action 
of  the  other,  in  pressing  upon  the  hypogastrium.  M.  Major  thinks 
that  we  can  maneuvre  with  the  same  hand  in  all  kinds  of  positions, 
but  always  in  conformity  to  the  rule  indicated  above.  For  this  end 
we  have  only  to  vary  the  posture  pf  the  woman,  to  place  her  on  one 
side  or  the  other,  or  on  the  back  or  abdomen,  accordingly  as  the 
abdominal  surface  of  the  fcetus,  for  example,  looks  to  the  right,  to  the 
left,  in  front,  or  to  the  rear ;  but  I  do  not  see  what  advantage  such  a 
course  can  have  over  the  one  generally  pursued  in  France  ? 

.  982.  Now  the  hand  being  chosen,  in  order  to  let  it  slip  easily 
through  the  passages,  render  its  introduction  easy,  and  guard  against 
the  infection  of  contagious  diseases,  We  should  cover  it  with  some  fatty 
or  mucilaginous  substance.  It  may  be  immersed  in  oil  or  mucilage, 
greased  with  butter,  lard,  or  the  white  of  eggs,  &c.  may  be  used:  which 
ever  of  these  substances  is  selected,  it  seems  to  me  right  always  to 
follow  the  counsel  of  Rocderer,  that  is  to  say,  only  to  annoint  the 
back  of  the  fingers  and  hand,  which  alone  exert  any  friction  upon 


4^  DYSTOCIA. 

the  parts  of  the  mother,  while  the  other  surface  of  the  hand  has  to 
do  only  with  bodies  that  are  already  but  too  slippery.  The  fore-arm 
ought  also  to  be  greased  as  far  as  its  upper  enw:  if  the  part  of  the 
child  we  are  to  pull  by  were  at  the  vulva,  or  not  high  up  in  the 
vagina,  this  precaution  might  be  rather  injurious  than  useful,  nntl 
the  hand  should  be  applied  quite  dry. 

.•*.*iiir- 

SECTION  2. 
"^"Y-  Version  by  the  Head. 

983.  Long  imbued  with  the  idea  that  the  positions  of  the  head 
were- the  only  ones  which  admitted  of  a  fortunate  delivery,  physi- 
cians only  thought,,  in  the  first  place,  of  restoring  that  part  to  the 
straits,  when  the  child  presented  otherwise  than  by  the  head  :  the 
precept  of  Hippocrates  was  followed,  and  they  endeavoured  to  bring 
down  the  head,  not  only  in  positions  of  the  shoulder  and  other 
regions  of  the  trunk,  but  also  in  those  of  the  breech,  knees,  and 
even  of  the  feet  themselves,  which  were  then  looked  upon  as  very 
dangerous.  Celsus  showed  that  the  foetus  might  escape  with  its 
lower  extremities  foremost ;  but  version  by  the  head  was  not  the  less 
regarded  as  the  safest  and  most  practicable  process,  until  the  time 
of  Franco  and  A.  Pare.  Since  the  time  of  Guillemeau,  on  the 
contrary,  it  has  been  almost  wholly  abandoned,  and  at  present  the 
standard  authors  scarcely  mention  it,  except  for  the  purpose  of  con- 
demning it.  Notwithstanding  what  a  few  modern  authors  have  said 
about  it,  no  person  in  France  has  felt  it  a  duty  to  put  it  in  practice. 
The  objections  urged  against  it  arc  the  difficulty  of  its  execution, 
the  smallness  of  the  hold- afforded  by  the  head  to  the  hand  that  at- 
tempts to  seize  it,  and  the  impossibility  of  bringing  it  back  to  the 
strait,  where  the  womb  is  ever  so  slightly  contracted  upon  the 
child  ;  that  even  in  the  most  favourable  cases,  where  turning  is  once 
effected,  the  hand  cannot  assist  in  the  delivery,  which  must  be  loft 
to  the  powers  of  nature,  unless  recourse  be  had  to  the  forceps  ; 
whereas,  by  acting  upon  the  feet,  it  is  an  easy  matter  to  extract  the 
fcctus  without  employing  any  instrument  but  the  hand  that  brought 
them  down.  Lastly,  that  as  delivery  by  the  pelvic  extremity  is 
almost  as  natural  as  by  the  heatj,  it  is  evidently  preferable  to  turn 
and  deliver  by  the  feet ;  and  that  it  is  the  only  method  that  ought  to 
bo  attempted  where  it  becomes  proper  to  change  the  position  of  the 
child. 

984.  To  the  above,  I  answer  :  1.  That  it  is  not  always  very  difficult 
to  take  hold  of  the  head  while  it  is  in  the  womb,  nor  to  exert  a  con- 


TURNING.  439 

siderable  degree  of  power  on  it  where  that  may  be  required;  2.  That 
unless  the  waters  have  been  long  discharged,  we  may  often  succeed, 
without  much  difficulty,  in  laying  hold  of  the  occiput,  and  bringing 
it  down  to  the  strait,  no  matter  how  far  it  may  have  been  removed 
therefrom  ;  3.  That  in  this  operation  we  have  not  so  much  to  catch 
hold  on  the  head  and  compel  it  to  descend,  as  to  push  up  the  part 
that  has  engaged  in  its  place  ;  4.  That  far  from  being  a  simple  and 
desirable  case,  a  delivery  by  the  pelvis,  on  the  contrary,  exposes  the 
child  to  the  greatest  danger,  while  that  by  the  vertex,  even  when  as- 
sisted by  the  forceps,  is  rarely  dangerous.  M.  Flamant  seems  to 
have  been  the  first  to  introduce  it  in  our  day  ;  notwithstanding  what 
Osiander  says  about  it,  who  has  attempted  to  divide  the  credit  of  it. 
In  fact,  the  German  prolessor  did  not  describe  it  until  1799, 
whereas  it  was  taught  at  Strasburgh  in  1798  ;  since  that  time  much 
attention  has  been  paid  to  it  in  the  north  of  Europe,  and  MM. 
Labbe,  Eckard,  Wigand,  Schnaubert,  Siebold,  d'Outrepont,  M. 
Wenzel,  Busch,  Carus,  Ritgen,  Schweighaeuser,  Toussaint,  Vallee, 
Deroche,  and  Ubersant,  have  expressed  themselves  more  or  less  at 
length  upon  turning  by  the  head,  and  endeavoured  to  diffuse  the 
principles  laid  down  by  Professor  Flamant. 

Cephalic  version  may,  therefore,  be  attempted,  1.  In  a  well 
formed  pelvis,  where  no  other  accident  has  happened  except  the 
vicious  position  of  the  fcEtus,  and  the  he&d  is  found  in  an  inclined 
position  in  the  vicinity  of  the  strait ;  2.  In  presentations  of  the 
shoulder,  back,  or  anterior  part  of  the  thorax,  provided  the  arm  is 
not  prolapsed,  and  the  uterus  not  too  much  contracted.  Lastly,  it 
seems  prudent  to  try  it  whenever  the  feet  are  farther  removed  from 
the  strait  than  the  head  is,  and  where  it  is  probable  that  the  labour 
would  terminate  spontaneously  if  the  head  were  at  the  strait. 
Moreover,  after  having  attempted  to  perform  it  in  vain,  we  are  not 
prevented  from  still  proceeding  in  search  of  the  feet,  ^frhich  can  be 
as  readily  found  after  as  before  the  attempt  has  been  made  :  if  the 
head  seems  disposed  to  come  down,  we  may  endeavour  to  bring  it 
down  ;  if  not,  we  have  only  to  direct  the  hand  towards  the  feet.  I 
do  not  think,  however,  that  this  kind  of  turning  ought  to  be  prefer- 
red in  the  inclined  positions  of  the  pelvis,  nor,  a  fortiori^  where  the 
breech  presents  fairly.  MM.  Flamant  and  Schweighaeuser  wish 
it  to  be  preferred  in  all  cases,  even  where  there  are  accidents  on  the 
part  of  the  mother,  because,  when  the  head  is  once  brought  to  the 
strait,  it  can  be  laid  hold  of  with  the  forceps.  Perhaps  they  might 
be  imitated  with  advantage  in  some  cases  where  the  foetus  is  very 
movable  in  the  uterus  ;  but  I  doubt  if  it  be  possible  where  the  waters 
are  gone  off",  and  the  womb  strongly  contracted  on  the  child. 


w 


43Q  DYSTOCIA. 

986.  Thus,  the  woman  being  placed  as  has  been  directed,  the 
left  hand  is  introduced  if  the  head  is  to  the  right,  and  tlic  right  hand, 
on  tlie  contrary,  if  to  the  left ;  and  either  one  or  the  other  almost 
indifferently,  if  the  vertex  is  turned  in  front  or  directly  behind. 

In  the  first  place,  the  part  that  is  engaged  is  to  be  pushed  up- 
wards ;  we  should  try  to  remove  it  from  the  strait,  and  direct  it  to- 
wards the  iliac  fossa  that  is  opposite  to  the  one  occupied  by  the 
vertex  ;  in  this  way  the  womb  is  enabled  to  exert  its  power  on  the 
head  and  return  it  to  the  centre  of  the  pelvis.  After  having  thus; 
raised  up  the  shoulder,  if  the  head  does  not  descend,  it  must  be 
sought  for  with  the  hand,  and  taken  hold  of  with  all  the  fingers,  which 
draw  it  down  as  with  a  crotchet,  and  at  the  same  time  endeavour 
to  make  it  assume,  in  preference,  one  of  the  occipito-anterior  po- 
sitions. When  the  head  has  been  brought  to  the  centre  of  the  pelvic 
circle,  it  is  left  there,  and  the  delivery  requires  no  further  assistance, 
provided  there  be  no  other  accident  in  the  case ;  if  the  contrary 
should  happen,  the  forceps  should  be  immediately  substituted  foi;> 
the  hand. 

Wigand,  in  speaking  of  cephalic  version,  says  that  we  may  often" 
succeed  in  operating  without  introducing  the  hand  into  the  genital 
organs ;  he  thinks  that  by  acting  upon  the  womb  through  the  abdo- 
minal parietes,  and  assisting  it  by  the  posture  of  the  woman,  we  may 
most  commonly  bring  back  the  head  to  the  superior  strait.  Before 
I  was  .acquainted  wiih  the  doctrine  o^  the  German  professor,  I  ha'di 
V  already  followed  this  precept,  and  have  in  conforming  to  it  found 
that  it  is,  in  fact,  sometimes  possible  to  restore  to  the  vertex  its  na- 
tural position ;  but  I  do  not  think  that  this  raancuvre  can  ever  be 
of  much  use  where,  the  waters  have  been  long  discharged,  and  the 
womb  strongly  contracted  on  the  child. 

SECTIONS. 


Of  Taming  by  the  Feefor  Pelms. 

The  maneuvrc  in  turning  by  the  feet  consists  of  three  principal 
stages.  It  is  necessary,  1.  To  introduce  the  hand;  2.  To  change 
the. position  of  the  child  ;  .3.  To  assist  in  the  expulsion  of  the  ovum. 

These  three  stages  are  never  found  together  in  turning  by  the 
head,  where,  as  has  been  already  seen,  the  action  of  the  hand  is  of 
no  further  use  after  the  head  has  been  properly  placed  at  the  supe- 
rior strait;  in  some  of  the  feet  positions  the  mancuvre  is  aJuoost 
wholly  confined  to  the  stage  of  extraction. 

986.   Introduction  tf  the  hand.     Many  authors  advise  us  to  pene- 


TURNING.  ^hW»    431 


trate  into  the  vagina  at  the  very  moment  of  a  strong  uterine  con- 
traction ;  in  this  way,  say  they,  the  pain  produced  by  the  operation 
becomes  confounded  vpith  the  pain  of  the  contraction,  and  the  wo- 
man does  not  distinguish  them  apart ;  then  also  the  vagina  is  both 
enlarged  and  shortened  by  the  temporary  descent  of  the  womb, 
which  in  some  sense  comes  down  to  meet  the  hand.  In  theory 
these  assertions  may  be  very  correct ;  but  in  practice  they  certainly 
do  not  authorize  the  precept  which  it  has  been  attempted  to  draw 
from  it,  and,  like  M.  Desormeaux,  I  think,  from  my  own  expe- 
rience, that  the  hand  should  generally  be  passed  through  tfic  vulva 
in  the  intervals  between  the  pains. 

Whatever  mode  be  adopted  on  this  point,  the  fingers  being  placed 
side  by  side,  must  first  be  introduced  in  the  direction  of  the  length 
of  the  vulva-;  after  which  they  are  brought  together  in  such  a  way, 
that  their  palmar  surface  forms  a  kind  of  gutter,  in  which  the  thumb 
is  lodged,  so  that  the  whole  may  form  a  very  long  cone,  the  base  of 
which  is  found  at  the  place  of  the  metacarpo-phalangial  articulations. 
The  hand  thus  gets  into  the  vaginal  cavity,  following  the  direction 
of  the  axis  of  the  inferior  strait. 

Q87.  In  order  to  penetrate  through  the  os  uteri,  it  is  absolutely 
necessary  to  choose  a  time  when  the  pain  is  ofi',  so  much  so,  that 
nobody  has  ever  dared  to  prescribe  the  contrary.  Otherwise,  in- 
deed, it  would  often  be  impossible  to  get  into  the  uterus;  there 
would  be  a  risk  of  lacerating  ti^  orifice  ;  in  fine,  it  would  be  volun- 
tapily  to  create  a  thousand  difiiculties,  and  to  expose  th&  woman  to 
numerous  dangers. 

If  the  dilatation  is  very  much  advanced,  the  fingers,  which  are  at 
first  held  together,  sliould  be  almost  immediately  more  or  less  sepa- 
rated, so  as  to  accommodate  them  to  the  form  of  the  part  that  pre- 
sents, and  allow  them  to  slip  easily  between  it  and  the  parietes  of 
the  womb.  In  the  contrary  case,  they  are  to  be  introduced  one 
after  the  other,  and  the  cone  formed  by  their  junction  is  soon  repro- 
duced. They  are  then  gently  passed  onwards,  taking  care  to  stop 
upon  the  recurrence  of  each  pain,  and  always  move  in  the  axis  of 
the  superior  strait.  Here  it  is  above  all  important  not  to  be  in  a 
hurry ;  for  the  movements  and  the  eflbrts  require  the  greatest  gen- 
tleness ;  instead  of  pressing  forwards  to  dilate  the  os  uteri,  it  is  some- 
times better  to  separate  the  base  of  the  fingers  moderately  and  by 
degrees,  or  at  least  the  portion  of  the  cone  already  introduced  into  the 
orifice.  During  this  maneuvre  the  other  hand  should  be  applied  to 
the  patient's  hypogastrium,  for  the  purpose  of  supporting  the  uterus, 
and  inclining  it  backwards  or  to  one  side  if  necessary.  As  soon  as 
the  roots  of  the  fiuger:^  have  pabiieU  through  the  os  uteri,  the  whole 


432  DYSTOCIA. 

hand  enters  without  difficulty  into  the  uterine  cavity,  and  thenceforth 
the  intromission  is  effected. 

988.  Period  of  exploration.  Before  proceeding  any  farther  the 
state  of  the  case  must  be  ascertained ;  we  must  be  sure  not  to  be 
deceived  as  to  the  position  of  the  foetus,  not  to  confound  the  arms 
with  the  legs,  to  see  if  any  part  is  twisted  out  of  its  proper  posit^n, 
and  endeavour  to  learn  where  are  the  feet  or  breech  after  having 
first  recognized  the  head.  Then,  to  get  hold  of  the  child  for  the 
purpose  of  extracting  it  or  changing  its  position,  it  is  essential  to 
remark*  that  several  points  of  its  body  could  not  bear  the  degree 
of  pressure  which  it  is  sometimes  found  to  be  necessary  to  exert. 
For  example,  we  ouglit  to  avoid  pressing  the  ends  of  the  fingers 
upon  the  sutures,  the  fontanels,  the  abdomen,  and  sides  of  the  tho- 
rax ;  for  the  purpose  of  pushing  up,  turning,  or  extracting  the  foetus, 
we  ought  to  apply  the  hand  only  to  the  forehead,  the  occiput,  the 
temples,  the  parietal  bones,  the  shoulders,  the  spine,  the  sternum, 
the  hips  and  the  limbs. 

989.  Mutation.  After  having  ascertained  the  part  that  presents, 
it  is  pushed  up  to  free  the  superior  strait,  taking  care  to  apply  the 
fingers  to  a  surface  as  extensive  as  possible  ;  then  the  feet  should  be 
sought  for,  seized,  and  brought  to  the  orifice.  The  foetus  must 
never  be  brought  down  otherwise  than  in  conformity  to  its  natHcal 
flexures  ;  that  is  to  say,  it  must  be  rolled  up,  on  its  anterior  surface. 
By  turning  it  over  backwards,  it  wauld  necessarily  be  brought  in 
the  direction  of  its  extension  ;  it  -would  soon  become  an  inflexible 
trunk,  or  arc  of  a  circle,  which  most  generally  would  render  the 
remainder  of  the  operation  impossible  ;  the  uterine  cavity  would  not 
be  suflicicntly  spacious  to  admit  of  the  evolution,  and  the  least  force 
would  hazard  the  luxation  or  fracture  of  the  limbs,  the  rupture  of  the 
spinal  marrow,  and  would  give  rise  to  extremely  severe  pains  on  the 
part  of  tho  woman,  and  perhaps  even  to  lacerations  of  the  uterus. 

Whilst  engaged  in  exploring,  and  turning  the  child,  it  is  not  less 
essential  to  support  the  womb  outwardly  than  it  is  during  the  time 
of  intromission.  The  hand  that  is  held  applied  to  tlie  hypogastrium 
may  aid  also  by  suitable  pressure  in  causing  the  head,  the  shoulder,  or 
the  limbs  to  descend,  wiiich  renders  the  turning  in  all  respects  easier 
and  surer  ;  but  for  this  precaution,  the  accoucheur  would  be  liable, 
when  compelled  to  exert  a  certain  degiee  of  force,  and  particulaB|| 
where  t].<  '  :  amnii  has  been  long  discharged,  to. produce  dan- 
gerous .M :  ^,  to  separate  the  vagina  from  the  cervix,  to  rup- 
ture the  womb  itself  at  some  weak  part,  qr  at  those  points  where 
the  womb  is  most  strongly  contracted  on  the  projecting  and  solid 
parts  of  the  foetus.     . 


TURNING.  .  433 

These  maneuvres  ought  always  to  be  executed  in  the  intervals 
between  the  pains  ;  they  would  be  excessively  dangerous  if  perform- 
ed during  the  contractions,  and  would  generally  occasion  fatal  lacer- 
ations to  take  place  ;  besides,  it  is  often  impossible  at  those  times 
to  move  the  foetus  ;  the  hand  soon  becomes  so  compressed  that  it  is 
quickly  benumbed,  and  completely  loses  all  its  powers  of  sensation 
and  motion  ;  as  soon,  therefore,  as  a  pain  appears,  all  exertion  is 
to  be  suspended  ;  it  should  not  be  begun  again  until  the  contrac- 
tion has  ceased,  unless,  however,  some  serious  circumstance  neces- 
sitates a  very  prompt  termination  of  the  labour. 

I  ought,  also,  to  warn  the  young  practitioner,  that  in  order  to  reach 
the  fundus  of  the  womb,  the  arm  must  be  introduced  much  farther 
than  he  would  at  first  suppose,  and  that  to  get  into  the  axis  of  the 
superior  strait,  the  hand  should  be  much  more  inclined  forwards 
than  would  be  imagined  upon  the  inspection  of  a  dried  pelvis. 

Most  accoucheurs  have  recommended  and  still  advise  that  the 
feet  should  be  seized,  and  not  any  other  part  of  the  limbs  ;  in  fine, 
the  feet  are  the  only  parts  by  which  we  are  advised  to  pull,  in  the  kind 
of  turning  under  consideration.  Nevertheless,  it  is  possible,  it  is  in 
many  cases  even  advantageous,  to  follow  the  counsel  given  first  by 
Burton,  reproduced  by  Delpech,  and  very  recently  again  by  Dr 
Breen — that  is,  to  take  hold  of  the  knees  or  hams,  rather  than  the 
feet. 

990.  Extraction.  When  the  mutation  has  been  completed,  and 
the  child  reduced  to  one  of  the  positions  of  the  extremities  of  its 
great  diameter,  we  may  stop,  provided  the  pelvis  be  well  formed 
and  the  womb  retains  sufficient  energy  to  terminate  the  rest  of  the 
labour.  This  is  the  way  we  are  compelled  to  act  in  all  cases  of 
version  by  the  head,  unless  we  choose  to  apply  the  forceps ;  but  when 
the  feet  are  brought  down,  ought  they  also  to  be  abatidoned  after 
they  are  placed  in  a  situation  which  no  longer  prevents  the  sponta- 
neous delivery  of  the  child  ?  To  authorise  this  advice  it  has  been 
supposed  :  1.  That  pulling  on  the  child  ought  always  to  be 
avoided  when  not  absolutely  necessary ;  2.  That  tractions  force 
the  arms  to  rise  along  side  of  the  head,  which  prevents  its  ad- 
vance, and  that  they  almost  always  place  the  occipito-frontal  or 
occipito-mental  diameters  in  the  situation  that  ought  to  be  occupied 
by  the  occipito-bregmatic  ;  3.  That  in  rapidly  passing  through  the 
OS  uteri,  the  belly  and  breast  of  the  foetus  are  subjected  to  too  sud- 
den a  compression  ;  4.  Lastly,  that  the  womb,  being  too  suddenly 
emptied,  may  become  inverted,  fall  into  inertia,  and  give  rise  to 
hemorrhage,  &c.  All  these  inconveniences  are  real,  and  nothing 
would  be  so  easy  as  to  enlarge  tiie  list ;  but  on  the  other  hand,  it 
3  E 


434  DYSTOCIA. 

should  not  be  overlooked  that  the  woman  submitted  to  the  opera- 
tion only  for  the  hope  of  being  soon  delivered  ;  that  her  family  and 
attendants  cannot  be  satisfied  until  the  child  is  completely  expelled  ; 
that,  in  case  of  abundant  hemorrhage,  of  syncope,  of  lipothymia, 
convulsions,  premature  descent  of  the  cord  and  exhaustion,  we 
have  no  right  to  wait ;  that  inertia  ought  rarely  to  occur  in  such 
circumstances,  seeing  that  the  maneuvre  is  better  calculated  to 
remedy  than  produce  it ;  that  the  compression  of  the  abdomen, 
when  the  hand  has  been  previously  introduced  into  the  womb,  ought 
not  to  inspire  any  great  alarm  ;  that,  at  least,  it  is  scarcely  more  to 
be  feared  where  we  draw  the  fcetus  down  by  the  hand,  than  where 
it  is  simply  pushed  down  by  the  efforts  of  the  mother  ;  lastly,  that 
it  is  possible  to  avoid  otie  extreme  without  falling  into  another,  and 
that,  it  is  as  dangerous,  in  the  practice  of  midwifery,  not  to  act 
apropos,  as  to  do  so  without  any  necessity. 

A  well  informed  and  prudent  man  will  therefore  preserve  a  just 
medium,  and  proportion  his  maneuvre  to  the  circumstances  of  each 
particular  case.  If  .not  pressed  by  any  important  circumstance,  he 
will  wait,  and  excite  the  uterine  actions  so  as  to  draw  the  child  down- 
wards concurrently  with  them,  for  the  two  actions  ought  to  be  so 
combined  as  to  constitute,  as  it  were,  but  one  ;  at  each  pain  the 
womb  ought  to  commence  before  the  hand,  and  finish  after  it.  By 
pursuing  this  course  we  imitate  a  spontaneous  delivery  ;  the  arms 
sometimes  descend  before  the  head,  which  continues  bent  down  upon 
the  breast,  and  the  occipito-bregmatic  diameter  does  not  lose  its 
natural  relation  to  the  straits  of  the  pelvis  ;  it  is  in  no  case  indis- 
pensably necessary  to  pull  hard  enough  to  rupture  the  spinal  mar- 
row or  detruncate  the  fcctus.  If,  on  the  contrary,  there  should  be 
no  other  chance  of  safety  either  for  the  mother  or  the  child,  than  in 
a  prompt  delivery,  and  should  the  contractions  of  the  womb  be  too 
slow  and  feeble  to  admit  of  his  relying  upon  them,  the  tractions  per- 
formed by  the  accoucheur  ought  not  only  to  assist,  but  they  should 
more  or  less  become  the  substitutes  of  the  powers  of  the  woman  : 
there  can  be  no  hesitation  in  such  a  case  ;  of  two  unavoidable  evils 
we  must  choose  the  least.  I  need  not  repeat  that  in  the  former  as 
well  as  in  the  latter  case  the  tractions  ought  to  be  performed  with 
great  caution,  never  by  jerks,  and  always  in  the  axis  of  the  straits. 

To  conclude,  extraction  may  be  considered  under  two  principal 
points  of  view  :  1.  As  a  mere  accessory  power  added  to  that  of  the 
womb,  and  which  hastens  the  termination  of  a  painful  function  ; 
2.  As  a  piincipal,  or  even  sole  resource,  in  cases  where  the  organism 
is  powerless,  or  where  it  is  of  importance  to  empty  the  uterus  within 
a  few  minutes.  This  distinction  being  once  established,  I  do  not  see 


TURNING.  435 

how  any  discussion  can  afterwards  arise  as  to  whether  the  child 
may  or  may  not  be  pulled  downwards  after  it  has  been  turned.  As 
long  as  the  tractions  are  confined  to  the  part  first  assigned  to  them, 
it  is  evident  they  can  be  only  of  service,  and  no  well  informed  man 
will  ever  make  use  of  thera  in  the  other  way  without  a  9learly  un- 
derstood necessity  for  so  doing, 

§.  I.  Of  bringing  down  the  feet  when  the  head  is  at  the  orifice. 

Relatively  to  turning  by  the  feet,  the  positions  of  the  head  ought  to 
be  reduced  to  two :  the  left  occipito-iliac,  to  which  we  bring  the 
first  and  fifth  of  Baudelocque ;  and  the  right  occipito-iliac,  which 
comprises  the  second  and  fourth  of  the  same  author,  to  which  also 
we  ought  to  bring  the  occipito  and  fronto-pubic  positions,  should 
they  be  met  with. 

991.  The  first  of  these  requires  the  left  hand,  and  the  right  band 
is  preferable  for  the  second. 

A.  Left  Occipito-iliac  Poalllons. 

992.  The  left  hand  enters  the  vagina  in  a  state  of  pronation, 
passes  along  the  anterior  face  of  the  sacrum,  penetrates  into  the 
orifice,  and  if  the  occiput  is  turned  directly  to  the  left,  remains  in  a 
state  of  semi-pronation,  approaches  a  state  of  supination  if  the  ver- 
tex is  in  the  first  position,  but  must  be  held  quite  prone  if  the  ver- 
tex is  turned  backwards  and  to  the  left,  dz.c.  The  head  is  to  be 
taken  hold  of  and  held  in  the  hand,  and  not  merely  with  the  points 
of  the  fingers.  The  thumb  is  placed  on  the  right  temple,  or  parietal 
protuberance,  and  the  other  fingers,  being  more  or  less  separated, 
are  applied  to  the  face  and  opposite  temple. 

At  first  this  part  is  thrust  upwards  and  along  the  axis  of  the  supe- 
rior strait,  that  is  to  say,  upwards  and  forwards  ;  it  is  afterwards* 
rejected  towards  the  left  iliac  fossa,  taking  care  to  favour  this  move- 
ment with  the  right  hand,  which,  being  placed  upon  the  hypogas- 
trium,  sustains  the  fundus  of  the  womb,  and  inclines  it  more  or  less 
backwards  and  to  the  right. 

993.  Now  is  the  time  to  go  in  search  of  the  feet :  for  this  end 
the  hand  may  pass  along  the  anterior  surface  of  the  child,  and  arrive 
directly  at  the  knees,  or  at  the  roots  of  the  thighs  ;  this  is  the  shortest 
route  ;  but  by  following  it  we  are  liable  to  several  errors,  in  short, 
to  mistake  the  elbow  for  the  knee,  the  foot  for  the  hand,  the  arms 
for  the  legs,  and  the  safest  way  is  to  act  in  the  following  manner  : 
we  begin  by  extending  all  the  fingers,  and  the  thumb  also,  towards 
the  left  side  of  the  head  ;  they  ought  to  be  placed  side  by  side,  and 
extended  in  order  to  occupy  the  least  possible  space  ;  they  are  then 


43(5  DYSTOCIA. 

passed  over  the  whole  of  the  left  lateral  surface  of  the  child,  by 
sliding  along  behind  the  neck,  the  shoulder,  the  breast,  the  flank 
and  the  hip  ;  during  all  this  time  the  anterior  part  of  the  wrist  sup- 
ports the  forehead  and  prevents  it  from  descending  again  into  the 
strait ;  the  other  hand  pushes  the  womb  backwards  as  much  as 
necessary  or  possible,  and  endeavours  to  bring  the  parts  we  are  try- 
ing to  get  hold  of  as  near  as  possible  to  the  fingers. 

994.  If  the  legs  are  in  their  natural  state  of  flexion,  we  endeavour 
to  carry  the  whole  hand,  flattened,  above  and  behind  the  breast, 
turning  it  more  and  more  into  a  state  of  pronation  as  we  proceed  ; 
if  they  are  on  the  contrary  turned  out  of  the  way  or  displaced  from 
their  natural  positions,  if  it  appears  too  difiicult  to  envelope  their 
posterior  surface  in  the  palm  of  the  hand,  we  should  take  hold  of 
both  of  them  if  possible,  or  at  least  that  one  which  is  nearest  the 
posterior  surface  of  the  womb,  embracing  their  root  with  the  thumb 
which  is  fixed  in  the  groin,  and  with  the  fingers  which  are  kept 
upon  the  posterior  surface  of  the  thighs.  Should  they  be  twisted 
or  crossed  ;  should  one  of  them  be  found  flexed,  and  the  other  ex- 
tended ;  finally,  if  we  have  attempted  in  vain  to  get  hold  of  them  both 
together,  and  should  be  obliged  to  bring  them  down  one  after  the 
other,  we  should  at  all  events  carefully  try  to  bring  down  the  pos- 
terior limb  first,  even  although  it  should  be  the  most  distant  one 
from  the  orifice. 

995.  In  the  first  case,  to  continue  the  operation,  the  hand  has 
only  to  slip  along  behind  the  thighs  and  legs,  which  it  pushes  before 
jt,  extending  them  as  they  come  down ;  in  this  way  the  feet  can 
neither  escape  nor  deviate,  and  may  be  conducted  without  difficulty 
to  the  superior  strait. 

In  the  second  case,  more  difliculty  is  generally  met  with  ;  we  are 
sometimes  obliged  to  act  successively  on  the  thigh  and  leg  as  if  they 
were  levers  of  the  first  kind  ;  while  we  are  searching  for  one  foot 
the  other  escapes,  and  it  is  always  a  difiicult  matter  to  draw  them 
both  down  together,  unless  we  have  been  so  fortunate  as  to  get  hold 
of  the  hams  with  the  fingers  and  thumb  at  tlie  commencement  of 
the  search. 

In  the  third  case,  that  is  to  say  when  the  limbs  are  far  removed 
from  their  natural  attitude,  and  always  when  we  are  obliged  to  bring 
them  down  one  after  the  other,  we  act  as  we  best  can  ;  only  we 
should,  while  pulling  at  the  leg  first  got  hold  of,  endeavour  to  make 
it  approach  the  opposite  limb  ;  by  abducting  it,  which  is  naturally  a 
very  limited  motion,  and  which  would  expose  the  child  to  the  risk 
of  luxations  or  fractures,  wc  should  also  have  the  disadvantage  of 
fatiguing  the  uterus  far  more  tlian  by  following  an  adductivc  move- 


TURNING.  437 

nient ;  for  its  free  exercise,  also,  the  last  named  movement  requires 
much  less  space  than  the  other. 

996.  However  it  may  be,  when  one  of  the  feet  has  reached  the 
vagina  or  the  vulva,  it  should  be  secured  by  means  of  a  fillet  pre- 
viously to  going  in  search  of  the  other ;  not  with  a  view  of  hindering 
it  from  mounting  upwards  again,  as  some  of  the  ancient  authors 
imagined,  but  only  that  it  may  be  found  again,  when  wanted.  This 
precaution  being  taken,  the  left  hand  is  again  carried  into  the  womb; 
and  that  it  may  more  readily  reach  the  other  foot,  it  should  follow 
along  the  inner  and  posterior  surface  of  the  one  held  in  the  fillet ; 
by  conforming  to  this  rule  we  necessarily  meet  with  the  crease  of 
the  breech  and  sexual  organs ;  the  thigh  we  are  in  search  of  cannot 
now  be  mistaken,  and  we  thus  avoid  a  good  deal  of  tiresome  feeling 
after  an  object.  It  ought  to  be  well  understood  that  this  foot  is 
to  be  brought  down  in  adduction,  by  following  the  anterior  surface 
of  the  foetus,  and  the  side  of  the  other  leg. 

After  having  succeeded,  in  any  way,  in  extending  the  legs,  and 
bringing  them  down  into  the  excavation,  we  place  the  index  between 
them  above  the  inner  ankles,  while  the  thumb  and  the  other  fingers 
are  applied  to  their  outer  surfaces,  and  in  such  a  way  that  the  heels 
lodge  in  the  palm  of  the  hand.  If  the  head,  forced  down  by  the 
womb,  or  ill  supported  by  the  wrist,  should  have  approached  too 
near  the  orifice,  we  should,  before  we  pull  the  feet  down,  and  with- 
out letting  them  go,  push  it  up  again  towards  the  left  iliac  fossa 
with  the  thenar. 

997.  The  first  object  of  the  tractions  now  to  be  performed,  is  to 
turn  the  child,  to  compel  the  head  to  rise  up  towards  the  fundus  of 
the  womb,  whilst  the  pelvis  is  drawn  into  the  superior  strait,  and  to 
convert  one  of  the  left  positions  of  the  vertex  into  one  of  the  right 
positions  of  the  feet ;  that  this  mutation  may  yield  all  the  advan- 
tages we  are  authorised  to  expect  from  it,  the  back  of  the  child 
must  always  turn  to  the  right,  then  a  little  in  front,  but  never  back- 
wards. Consequently,  the  operator  will  carefully  avoid  inclining 
the  hand  in  supination,  after  he  has  begun  to  pull  on  the  legs ;  he 
should  keep  it  in  semi-pronation,  to  reduce  to  the  second  position  of 
Baudelocque  ;  and  even  if  that  should  not  suffice,  he  ougTit  to  try  to 
get  the  right  foot,  which  is  in  front,  with  the  right  hand,  and  draw 
down  solely,  or  almost  solely,  by  it,  until  the  tendency  of  the  back 
to  direct  itself  backwards  shall  have  been  overcome. 

998.  As  soon  as  both  of  the  feet  have  passed  through  the  vulva, 
they  should  be  wrapped  in  a  dry  cloth  so  that  they  may  be  held 
more  firmly.  The  hips  soon  pass  through  the  orifice,  and  present 
at  the  inferior  strait.     As  the  limbs  come  forth,  the  hands,  which 


438  DYSTOCIA. 

are  applied,  the  right  one  in  front  and  the  left  one  behind,  ought 
to  extend  along  them  towards  the  vulva,  so  as  to  hold  them  by  as 
large  a  surface  as  possible ;  the  thumbs  are  therefore  placed 
behind,  the  two  last  fingers  on  the  anterior  surface,  and  the  index 
and  medius  extended  on  the  outside  of  each  leg  or  each  thigh,  until 
the  hips  shall  have  been  born. 

999.  Before  proceeding  any  further,  it  is  proper  to  attend  to 
the  umbilical  cord,  to  see  that  it  be  not  stretched,  by  carrying  the 
index  and  the  thumb,  or  two  other  fingers  of  the  right  hand,  towards 
its  insertion  on  the  belly  of  the  child.  If  it  should  be  found  tense, 
a  loop  of  it  of  sufficient  length  should  be  brought  down  by  pulling 
the  placental  portion,  but  never  by  pulling  its  abdominal  portion  ;  if 
it  is  found  not  to  be  stretched  any  about  the  navel  it  may  be  let 
alone ;  if  it  should  proceed  from  the  navel  down  betwixt  the  thighs 
and  then  mount  up  along  the  child's  back,  so  that  the  circulation 
should  appear  to  suffer,  it  ought  to  be  disengaged,  and  even  divided, 
should  the  danger  appear  to  be  pressing,  and  no  other  means  of 
disengaging  the  limbs  be  discoverable  ;  but  after  that  the  labour 
ought  to  be  terminated  within  a  very  few  minutes. 

1000.  We  continue  the  tractions  obliquely  downwafds  and  back- 
wards, that  is  to  say,  in  the  axis  of  the  superior  strait.  As  the 
hips  are  disengaged  they  are  in  turn  taken  hold  of,  the  left  or  pos- 
terior one  with  the  left  hand,  and  vice  versa,  but  in  such  a  way 
that  the  fingers  are  not  applied  higher  up  than  the  crista?  of  the 
ilia,  so  as  to  avoid  pressing  upon  the  abdominal  viscera.  The  belly 
and  the  breast  soon  follow  ;  this  is  the  time  that  the  arms  rise  up- 
wards, that  the  shoulders  engage,  and  that  it  is  essentially  important 
to  combine  the  efforts  of  the  accoucheur  with  those  of  the  woman, 
in  order  to  avoid  a  departure  of  the  chin  from  the  breast.  What- 
ever resistance  may  be  met  with  in  engaging  the  shoulders  in  the 
excavation,  we  ought  never  to  imitate  those  routine  practitioners, 
who,  while  they  are  pulling  the  child  downwards,  can  never  think  of 
any  thing  better  than  to  make  it  revolve  on  its  axis,  or  make  its 
whole  body  perform  a  more  or  less  extensive  movement  of  circum- 
duction ;  neither  should  we  move  it  alternately  from  the  internal 
surface  of  olie  thigh  to  that  of  the  other,  nor  raise  and  depress  it  by 
turns  from  sacrum  to  pubis  and  vice  versa ;  such  maneuvres  could 
not  do  any  good,  and  would  stretch  the  dorsal  or  cervical  portions 
of  the  spine  too  dangerously  ;  when  it  is  found  insufficient  to  draw 
downwards  in  the  direction  of  the  straits,  it  may  be  barely  proper 
to  try  the  effect  of  diagonal  traction^,  that  is  to  say,  we  may  pull 
downwards  towards  that  oblique  diameter,  wbicb  at  the  superior 
strait  corre.sponds  to  the  greatest  diameter  of  tlie  shoulders.     In  the 


TURNING.  439 

first  place,  while  continuing  to  pull  gently,  we  raise  up  the  child's 
pelvis,  as  if  we  intended  to  carry  it  towards  the  mother's  left  groin  ;  it 
is  then  depressed  towards  tlie  right  sacro-sciatic  notch  ;  afterwards 
we  continus  to  raise  and  depress  it,  until  the  shoulders,  which  in  this 
way  engage  one  after  the  other,  and  receive  the  greatest  part  of  the 
force  employed,  are  near  enough  to  the  inferior  strait  tp  be  easily 
got  hold  off;  when  the  child  has  advanced  thus  far,  we  must  attend 
to  the  extraction  of  the  arms. 

1001.  When  the  child  is  small  or  the  pelvis  very  large,  the  pre- 
sence of  the  arms  offers  but  a  small  obstacle  to  the  escape  of  the 
head,  and  we  ought,  properly,  to  abstain  from  disengaging  them ; 
but,  in  all  other  cases,  they  could  not  fail  to  embarrass  the  rest  of 
the  operation,  and  prudence,  if  not  an  indispensable  necessity,  re- 
quires that  they  should  be  brought  down.  Some  authors  have  saifl, 
that  when  applied  alongside  of  the  neck,  they  facilitate  the  passage 
of  the  head,  the  dilatation  of  the  vulva,  that  they  obviate  the  con- 
traction of  the  uterine  circle,  and  the  strangulation  of  the  foetus, 
and  that  they  are  never  so  large  as  to  prevent  the  delivery  from 
taking  place  ;  but  as  this  opinion  is  not  founded  on  any  plausible 
reason,  it  does  not  deserve  the  trouble  of  being  opposed,  and  at 
present  no  one  follows  the  practice. 

The  member  nearest  the  sacrum  must  always  ^  extracted  first ; 
should  we  begin  with  the  other,  we  should  meet  with  great  difficul- 
ty, and  when  we  had  succeeded,  the  other  arm  would  not  be  found 
to  be  at  all  more  free. 

1002.  The  trunk,  which  should  always  be  wrapped  up  in  a  cloth, 
is  supported  by  the  right  hand,  as  it  is  performing  the  oblique  trac- 
tions. The  left  thumb,  in  a  state  of  pronation,  is  placed  in  the  hol- 
low of  the  corresponding  axilla,  while  the  index  and  medius  are 
applied  to  the  outer  and  anterior  surfaces  of  the  arm,  as  far  as  the 
bend  of  the  elbow,  as  if  to  form  a  tackle  for  the  humerus.  We 
then  act  upon  the  whole  arm  as  upon  a  lever  of  the  third  kind  ;  the 
thumb  represents  the  fulcrum,  the  fingers  the  power,  and  the  resist- 
ance is  found  in  the  forearm  of  the  child.  While  we  are  thus  act- 
ing on  the  arm  to  bring  it  down,  it  must  be  carried  in  the  direction 
of  adduction,  so  that  as  it  sinks  down  it  may  slide  over  the  fore  part 
of  t^je  breast.  If  we  should  be  content  with  hooking  it  with  one  or 
two  fingers,  we  would  run  a  risk  of  fracturing  the  bone,  or  at  least 
of  exerting  the  force  only  upon  the  shoulder-joint.  When  the 
whole  shoulder  is  much  elevated,  it  is  sometimes  found  advanta- 
geous to  follow  the  advice  of  Baudelocque,  which  has  been  re- 
peated by  almost  all  the  accoucheurs  of  our  own  day,  namely,  to 
divide  this  little  operation  into  two  stagers,  to  put  the  hand,  at  first 


440  Dystocia. 

in  pronation,  so  that  the  thumbmay  for  an  instant  take  the  place 
of  the  other  fingers,  and  operate  in  succession  upon  the  whole  limb, 
beginning  at  the  root  of  it ;  but  this  precaution  is  most  frequently 
unnecessary,  antl  I  have  had  no  occasion  to  repent  of  having  gene- 
rally neglected  it. 

The  arm  having  been  brought  down,  it  is  to  be  extended  along 
the  side  of  the  thorax  ;  the  right  hand  deposits  the  trunk  of  the 
child  in  the  left  hand,  and  then  proceeds  to  disengage  the  anterior 
or  sub-pubal  member,  according  to  the  method  indicated  above. 

1003.  Instead  of  following  their  natural  tendency  to  rise  up  along- 
side of  the  head,  the  arms  are  sometimes  turned  backwards,  and 
that  in  two  different  ways  :  1 .'  One  of  them,  or  both,  but  generally 
only  one,  arid  especially  the  one  that  ought  to  be  found  in  front,  is 
fixed  behind  the  neck,  so  as  to  arrest  the  progress  of  the  occiput ; 
2.  Previously  to  rising  upwards,  or  even  'while  in  the  act  of  rising, 
they  get  behind,  and  cross  each  other  upon  the  back,  below  the 
shoulders,  which  may  occasion  their  being  luiated,  or  even  fractur- 
ed, and  greatly  increase  the  difficulties  of  the  maneuvre,  provided 
it  be  not  remedied  in  good  time. 

-*In  the  first  case,  we  commence  by  disengaging  the  arm  that  is  not 
deviated  ;  we  then  push  the  trunk  up  a  little',  so  as  to  compel  the 
head  to  rise,  and#s  far  as  possible  to  diminish  the  pressure  upon 
the  other  arm  ;  ^fter  which  the  fingers  and  the  thumb  ought  to  be 
applied  as  has  been  already  directed,  and  act  upon  the  same  prin- 
ciples, but  with  rather  more  gentleness.  If  the  arm  resists,  we 
attempt  to  make  it  rise  up  above  the  occiput,  and  the  blunt-hook 
proposed  by  M.  Dubois  ought  not  to  be  employed  until  all  other 
attempts  shall  have  proved  to  be  insufficient. 

In  the  second,  even  although  the  forearm  should  have  passed 
quite  across  to  the  opposite  side,  as  seems  to  have  happened  in  a  case 
under  the  care  of  M.  Dugus,  and  even  though  it  should  have  risen 
as  high  as  the  nucha,  it  ought  always  to  be  hooked  with  the  middle 
and  fore  finger  to  draw  it  down  along  the  child's  back,  and  bring  it 
out  of  the  vulva  ;  it  is  generally  pretty  easy  to  succeed  in  this  ma- 
neuvre, but  the  breast  has  sometimes  to  be  pushed  strongly  up,  or 
the  trunk  more  or  leas  considerably  rotated, ^before  it  can  bo  ef- 
fected. 

1004.  Should  the  exertions  of  the  accoucheur  have  beerf  well 
seconded  by  the  contractions  of  the  womb,  the  head  ought  now  to 
have  descended  into  the  excavation,  or  at  least  be  considerably  en- 
gaged within  the  superior  strait,  so  that  the  occipito-bregmalic  and 
bl'parictal  diameters-  would  be  found  to  be  in  proper  relation  to  the 
oblique  diameters  of  the  pelvic  circle. 


TURNING.  441 

In  that  case,  the  right  hand,  passing  along  the  front  of  the  breast 
and  throat,  penetrates  in  a  flattened  and  half-supine  position  quite 
into  the  vagina  ;  the  thumb  and  two  last  fingers  are  placed  on  the 
sides  of  the  throat ;  the  index  and  raedius  should  be  directed  on  to 
the  chin,  or  in  the  mouth,  or  what  is  still  better,  on  each  side  of  the 
nose,  for  the  purpose  of  keeping  the  head  in  its  natural  state  of 
flexion,  and  approximate  the  facial  extremity  of  the  occipito-mental 
diameter  as  much  as  possible  to  the  sternum  ;  after  having  placed 
the  right  hand  properly,  the  foetus  is  to  be  laid  on  its  belly  upon  the 
anterior  surface  of  the  corresponding  arm,  whicb^  is  then  much 
depressed  towards  the  perineum,  without,  however,  pulling,  for  the 
object  at  that  moment  is  merely  to  disengage  the  vertex  from  the 
pubic  arch.  In  the  next  place,  two  or  three  of  the  first  fingers  of 
the  left  hand  are  to  be  carried  under  the  occiput,  to  sustain  it,  and 
prevent  it  from  engaging  before  the  chin  ;  the  thumb,  the  other 
fingers,  and  the  rest  of  this  hand  are  applied  naturally  behind  the 
neck,  and  we  attempt  to  push  the  head  upwards  in  the  axis  of  the 
superior  strait,  so  as  to  cause  it  more  easily  to  perform  its  pivot- 
motion. 

When  we  have  succeeded  in  getting  the  face  into  the  hollow  of 
the  sacrum  and  the  occiput  behind  the  symphysis,  we  should  wait 
for  a  pain ;  the  woman  should  be  told  to  bear  down,  and  the  two 
hands  being  fixed  as  has  been  stated,  we  immediately  begin  to  exert 
some  tractive  force  on  the  head,  which  is  gradually  drawn  down  in 
the  axis  of  the  straits,  while  at  the  same  time  the  trunk  of  the  child 
is  gradually  raised  upwards,  as  if  we  were  going  to  turn  it  over  on 
to  the  hypogastrium  of  the  mother. 

lOOS,  When  the  efforts  of  the  accoucheur  have  not  been  suflli- 
ciently  seconded  by  the  contractions  of  the  womb,  or  when,  after 
the  delivery  of  the  shoulders,  the  head  has  not  performed  its  flexion 
movement,  and  is  found  to  be  arrested  at  the  superior  strait,  it  is 
sometimes  very  difficult  to  reach  it,  and  still  more  so  to  get  it  down  ; 
however,  until  we  can  reach  it,  all  tractive  force  on  the  trunk  is  to 
be  suspended,  for  it  would  only  tend  to  reverse  it  still  more.  The 
hands,  placed  as  before,  should  be  carried  further  up.  At  this  junc- 
ture it  is  particularly  useful  to  apply  the  forfe  and  middle  fingers  to 
each  side  of  the  nose ;  for  by  applying  them  to  the  inside  of  the 
mouth,  there  would  be  a  risk  of  depressing  the  lower  jaw  only,  or 
of  luxating  it  or  straining  it  to  an  injurious-degree  ;  but  in  this  case 
also  it  is  most  difficult  to  reach  this  part  of  the  face ;  and  further,  it 
must  be  confessed  that  when  we  have  reached  it,  if  a  good  deal  of 
force  is  required,  the  fingers  slip  and  get  oflf  from  it  with  surprising 
facility  ;  so  that  we  are  mostly  under  the  necessity  of  fixing  them  on 
3F 


443  DYSTOCIA. 

the  most  movable  part  of  the  face,  a  part  the  least  calculated  to  bear 
the  force  necessary  to  make  the  head  turn  forwards. 

1006.  It  is  therefore  indispensably  necessary  to  stimulate  the 
action  of  the  womb  or  that  of  the  abdominal  muscles  ;  as  the  efforts 
of  the  woman  oblige  the  anterior  or  mental  branch  of  the  sort  of 
lever  represented  by  the  head  to  descend  first,  the  least  pulling  at 
the  jaw  in  a  direction  from  above  downwards  is  then  very  effica- 
cious ;  those  tractions,  on  the  contrary,  which  the  accoucheur  exerts 
on  the  trunk  of  the  body,  being  more  particularly  transferred  to  the 
occiput,  tend  naturally  to  produce  the  inverse  effect  of  the  one  we 
wish  to  obtain.  It  is  therefore  essential  not  to  pull,  except  upon  the 
face,  whether  there  be  any  pains  or  not,  until  we  have  brought  the 
occipito-bregmatic  diameter  of  the  head  to  correspond  with  one  of 
the  diameters  of  the  pelvis. 

1007.  To  the  inconvenience  of  a  reversion  of  the  head  there  is- 
sometimes  added  another  that  never  fails  to  be  embarrassing  ;  in- 
stead of  looking  backwards  and  to  the  left,  or  directly  left,  the  face 
is  sometimes  found  to  turn  more  or  less  in  front,  or  directly  back- 
wards, so  that  the  neck  is  twisted  round  on  its  own  axis.  In  this 
state  of  things  all  tractions  on  the  trunk  of  the  body  would  be  dan- 
gerous. Previously  to  doing  any  thing  of  that  sort,  we  ought,  in 
the  absence  of  a  pain,  to  push  up  the  breast,  and  take  hold  of  the 
chin  with  two  fingers  of  the  right  hand,  disengage  it  and  direct  it 
towards  the  sacro-iliac  symphysis,  while  with  the  left  hand  on  the 
hypogastrium  we  favour,  first  the  rotation,  and  then  the  flexion  of 
the  entire  head  ;  afterwards  we  proceed  as  in  the  former  case. 

B.  Right  oecipito-iliae  position. 

1008.  In  the  third  and  sixth  positions  of  Baudelocque,  we  might, 
strictly  speaking,  use  the  left  hand  with  the  same  facility  as  the 
right ;  but  the  latter  is  preferred  because  it  terminates  the  delivery 
in  the  first  position  of  the  feet,  which  appears  to  be  rather  more 
advantageous  than  the  second,  and  because  we  can  generally 
maneuvre  with  it  better  than  with  the  other  hand. 

1009.  Whether,  therefore,  the  occiput  be  towards  the  pubis,  the 
sacrum,  the  right  acelabulum,  or  the  right  sacro-iliac  symphysis,  the 
right  hand  ought  always  to  be  made  use  of,  in  a  supine  position  in 
the  first  case,  prone  in  the  second,  half  supine  in  the  third,  and  in  a 
state  of  semi-pronation  in  the  fourth.  By  placing  the  thumb  on  the 
left  temple,  and  the  fingers  on  the  opposite  temple  and  side  of  the 
face,  we  can  embrace  the  head  in  the  hand,  raise  it  up  in  the  axis 
of  the  superior  strait,  push  it  towards  the  right  iliac  fossa,  and  then 
reach  the  car  of  the  same  side,  so  that  the  hand  may  be  supine,  and 


TURNING.  443 

the  thumb  brought  close  to  the  radial  side  of  the  index  finger  ;  the 
hand,  being  then  flattened  out,  may  slip  all  along  the  child's  right 
side,  and  as  it  becomes  prone,  get  hold  of  the  feet,  and  act  in  all 
respects  as  the  left  hand  does  in  a  left  occipito-iliac  position. 

1010.  When  the  face  presents  firsts  the  maneuvre  does  not  sen- 
sibly differ  from  that  which  is  used  for  the  positions  of  the  vertex. 
The  right  hand  is  always  to  be  introduced  >vhere  the  chin  is  to  the 
left,  in  front,  or  to  the  rear ;  or  to  speak  more  generally,  and  per- 
haps also  more  correctly,  the  right  hand  is  to  be  employed  in  all 
cases  where  it  seems  easier  to  push  the  forehead  towards  the  right 
iliac  fossa  than  towards  the  opposite  one — and  the  left  hand  in  all 
other  cases. 

1011.  The  other  inclined  positions,  that  is  to  say,  those  of  the 
temples  and  posterior  part  of  the  occiput,  when  they  cannot  be  early 
reduced  to  the  corresponding  ones  of  the  vertex,  are  classed  among 
the  positions  of  the  trunk  of  the  body,  whence  it  manifestly  follows, 
that  in  turning  by  the  feet  there  can  be  only  two  positions  of  the 
head  ;  therefore,  as  these  two  positions  themselves,  as  to  their  prac- 
tical indications,  differ  only  in  one  requiring  the  right  hand  more 
particularly,  and  the  other  the  left  hand,  and  as  it  is  only  necessary  to 
transpose  to  the  right  hand  the  rules  already  laid  down  for  the 
government  of  the  left — it  is  clear,  in  point  of  fact,  that  all  the 
maneuvres  of  the  head  are  naturally  reduced  to  a  single  one,  and 
that  by  multiplying  them,  we  naturally  fall  into  fastidious  repetitions, 
evidently  of  no  use,  and  fit  for  nothing  but  to  overload  the  memory 
of  the  student. 

§.  II.  Of  turning  by  the  feet  in  presentations  of  the  trunk;, 

1012.  Although  it  may  not  be  certain  that  no  case  has  been 
seen,  in  a  well  formed  pelvis,  where  the  trunk  of  the  foetus  was  so 
situated  that  the  head  was  turned  directly"back wards  ;  although  it  is 
difficult  to  conceive  of  such  a  phenomenon,  an  error  was  commit- 
ted by  those  who  maintain  that  the  same  holds  good  of  the  anterior 
part  of  the  pelvic  circle.  The  ossa  pubis  being  lower  than  the 
sacro«  vertebral  angle,  and  the  soft  parietes  of  the  abdomen  being  very 
distensible,  the  posterior  concavity  of  the  symphysis  does  not,  like 
the  projection  of  the  spine,  repel  the  head  towards  the  sides  of  the 
median  line,  and  admit  of  its  fixing  itself  directly  in  front. 

1013.  Besides,  this  last  mentioned  position  has  been  many  times 
met  with.  To  the  proofs  already  in  possession  of  the  profession  on 
this  subject,  I  might  add  several  more  ;  but  I  shall  content  mysell 
with  citing  only  one.  A  woman,  in  her  fourth  pregnancy,  and 
whose  former  .labours  had  exhibited  nothing  peculiar,  continued 


444  DYSTOCIA. 

several  days  in  labour  at  my  amphitheatre  ;  she  was  carefully  atten- 
ded to  by  the  students,  and  all  of  them  had  an  opportunity  of  satis- 
fying themselves  that  the  right  shoulder  was  at  the  orifice,  while 
through  the  remarkably  thin  parietes  of  the  abdomen  the  head  could 
be  felt  almost  naked,  above  and  in  front  of  the  symphysis  pubis. 
However,  as  these  positions  are  rare,  and  do  not  at  all  alter  the  fun- 
damental rules  of  the  maneuvre,  I  shall  refer  all  the  presentations  of 
the  trunk,  as  I  have  done  those  of  the  head,  to  two  principal  ones  : 
namely,  a  left-lateral  one,  comprising  the  first  and  fourth  of  MM. 
Maygrier,  Capuron,  Duges,  and  Madame  Lachapelle  ;  and  a  right 
lateral  one,  to  which  the  second  and  third  of  the  same  authors  must 
be  reduced. 

In  fact,  what  does  it  import  to  the  hand  with  which  we  operate, 
whether,  in  presentations  of  the  side  for  example,  the  head  is  a  lit- 
tle nearer  or  a  little  further  off  from  the  anterior  or  posterior  me- 
dian line  of  the  pelvis  ?  If  we  wish  to  take  hold  of  the  posterior  sur- 
face of  the  child's  legs,  we  shall  still  be  obliged  to  deliver  in  the  first 
position  of  the  feet  if  we  use  the  right,  and  in  the  second  if  we  use 
the  left  hand  ;  as  we  always  have  to  bring  the  child  as  near  as  pos- 
sible to  a  transverse  position,  in  turning  there  will  be  rather  more 
difficulty  in  those  cases  where  it  is  farthest  removed  from  that  posi- 
tion, and  rather  less  where  it  is  nearest  to  it ;  but  there  is  no  other 
difference,  and  surely  that  is  not  enough  to  justify  the  importance 
attributed  by  modern  writers  to  the  question,  whether  the  cephalo- 
anterior  positions  of  the  trunk  ought  or  ought  not  to  be  admitted. 

1014.  I  have  already  pointed  out  the  reasons  that  induce  me  to 
admit  the  possibility  of  presentations  both  of  the  anterior  and  pos- 
terior surfaces  of  the  foetus  ;  although  they  in  reality  require  the 
same  maneuvre  as  those  of  the  lateral  regions,  I  shall  say  a  few 
words  about  them  notwithstanding,  and  successively  pass  in  review 
the  positions  of  the  side,  the  posterior  and  anterior  surfaces,  taking 
care  meanwhile  to  dwell  only  upon  those  to  which  a  major  part  of 
the  others  ought  to  be  reduced  in  operating. 

A.  Positions  of  the  Shoulder  and  Side. 

1015.  By  following  a  numerical  order  in  indicating  positions,  so 
much  confusion  has  been  introduced,  that  it  is  almost  impossible  for 
students  to  understand  each  other  if  they  happen  not  to  have  studied 
the  same  books.  Thus,  to  speak  only  of  positions  of  the  trunk,  in 
Baudelocque's  first  the  head  is  in  front,  in  front  and  to  the  left  ac- 
cording to  Maygrier,  and  directly  to  the  left  according  to  M. 
Gardien  :  now,  as  this  mode  of  proceeding  is  entirely  arbitrary,  and 
as  nothing  can  provcntonc  accoucheur,  if  he  chooses,from  calling  that 


SHOULDER  POSITIONS.  445 

a  first  position  which  another  chooses  to  denominate  the  third,  I 
have  thought  I  might  arrange  all  the  shoulder  presentations  under 
the  titles  of  dorso-pubic,  dorso-sacral,  and  right  or  left  dorso-iliac. 
This  is  the  way  to  avoid  all  ambiguity,  and  reduce  to  their  just  value 
the  numerous  classifications  which  have  successively  appeared  in 
France  sance  the  time  of  Solayres. 

'  ^''  1.  Positions  of  the  Left  Shoulder. 

1016.  Dorso-sacral  position  (3d  of  Baudelocque).     In  this  po- 
iJ;'-.8ition,  the  head,  which  is  on  the  left  side,  maybe  stopped  above  the 

foramen  miale.^  the  sacro-iliac  symphysis,  or  even  the  iliac  fossa ; 
being  referable  to  the  corresponding  varieties  of  the  vertex  positions, 
its  different  shades  require  to  be  operated  on  like  the  left  occipito- 
iliac  position.  Only,  instead  of  the  head,  it  is  the  shoulder  that  is 
to  be  pushed  up,  and  instead  of  placing  the  thumb  and  fingers  on 
the  temples,  they  are  to  be  applied  to  the  back,  and  to  the  fore  part 
of  the  thorax ;  in  fact,  turning,  in  this  case,  differs  from  that  in  ver- 
tex positions,  only,  in  respect  that  the  head  is  already  raised  or  re- 
versed, and  that  the  first  stage  of  the  operation  is  effected  by  natural 
means. 

1017.  The  left  hand  is  to  be  introduced;  the  thumb  is  to  be 
pressed  on  the  anterior  face  of  the  shoulder  or  the  sternum ;  the 
other  fingers  sHp  behind  the  scapula  or  chest,  and  the  little  finger 
remains  turned  towards  the  child's  occiput. 

To  conform  to  this  rule,  the  hand  ought  to  be  introduced  half 
supine,  or  in  a  more  or  less  complete  state  of  supination  or  prona- 
tion, accordingly  as  the  vertex  happens  to  be  near  the  symphysis 
pubis,  the  sacro-vertebral  angle,  or  the  iliac  fossa;  after  having 
raised  up  the  shoulder,  taking  care  at  the  same  time  to  push  it 
backwards  so  that  the  anterior  surface  of  the  foetus  may  look  some- 
what downwards,  we  should  endeavour  to  push  the  head  towards 
the  middle  of  the  iliac  fossa,  provided  it  were  at  too  great  a  dis- 
tance from  it  before,  which  often  requires  a  skilful  combination  of 
the  efforts  of  the  hand  that  presses  upon  the  hypogastrium  with 
those  of  the  one  which  is  operating  in  the  womb.  The  thumb  then 
abandons  the  sternum,  is  placed  alongside  of  the  index,  and  for  the 
remainder  of  the  procedure  we  act  as  was  directed  in  speaking  of 
the  left  occipito-iliac  position. 

1018.  When  the  head  is  found  completely  in  front  (left  dorso- 
iliac  position),  or  even  somewhat  near  the  right  acetabulum,  we  may 
proceed  as  above ;  only  that  in  order  to  get  hold  of  the  right  shoul- 
der, the  hand  is  in  a  forced  state  of  supination,  and  that  after  having 
lifted  it  up,  the  head  is  to  be  carried  from  right  to  left,  as  far  as  pos- 


446  DYSTOCIA. 

sible,  towards  the  iliac  fossa,  by  acting  chiefly  with  the  thumb  ex- 
actly applied  to  the  sternum. 

In  cases  where  it  is  situated  very  near  the  posterior  median  line 
(right  dorso-iliac  position),  it  is  very  difficult  to  bring  it  back  to  the 
left  extremity  of  the  great  diameter  of  the  pelvis,  because  the  thorax 
only  moves,  whereas  the  head  retains  its  primitive  position.  To 
overcome  this  difficulty,  we  are  to  support  the  upper  part  of  the 
chest  with  the  thumb  and  fore  finger,  while  the  others  are  extended 
as  far  as  the  occiput,  and  thus  serve  to  push  from  behind  forwards, 
and  from  right  to  left,  as  if  we  wished  to  tilt  it  over  from  the  occiput 
towards  the  chin. 

1019.  Dorso-pubcd  positio7i  (4th  of  Bsiudelocque).  The  maneu- 
vre  is  generally  much  more  difficult  in  this  than  in  the  preceding  po- 
sition, for  it  can  scarcely  be  terminated  without  first  being  converted 
into  a  left  cephalo-iliac  position,  or  into  a  position  of  the  right  side. 
But,  in  either  of  these  cases,  the  change  we  are  obliged  to  make  in 
the  situation  of  the  fcetus  is  so  great,  that  if  it  be  somewhat  com- 
pressed by  the  uterus,  its  life  is  often  found  to  be  exposed  to  the 
greatest  dangers.  This  is  certainly  a  case  where  it  would  be  pro- 
per to  bring  the  head  to  the  orifice,  and  afterwards  apply  the  for- 
ceps, instead  of  turning  and  delivering  by  the  feet. 

1020.  However  this  may  be,  provided  the  waters  have  not  been 
long  discharged,  if  the  membranes  are  not  ruptured,  and  lastly,  if 
the  child  is  to  a  certain  extent  movable  in  the  womb,  the  best  prac- 
tice is  to  reduce  it  to  a  dorso-sacral  or  left  dorso-iliac  position :  this 
may  be  effected  in  two  different  ways. 

Unless  the  head  happens  to  be  nearer  to  the  sacro-iliac  symphysis 
than  to  the  right  acetabulum,  we  might,  by  turning  the  hand  into  a 
very  forced  state  of  supination,  get  hold  of  the  shoulder,  as  in  the 
cases  heretofore  treated  of,  that  is,  so  that  the  thumb  may  tend  to 
reach  the  sternum  whilst  the  fingers  remain  behind  the  thorax,  the 
little  finger  being  towards  the  head ;  then  we  act  by  raising  it  up- 
wards a  little,  the  vertex  in  front;  tlie  hand  afterwards  assumes 
during  the  operation  an  attitude  of  pronation,  which  is  more  and 
more  complete  in  proportion  as  the  occiput  moves  more  towards 
the  left  iliac  fossa. 

1021.  Should  it  be  too  difficult  thus  to  move  the  cephalic  extre- 
mity of  the  child,  from  right  to  left,  over  the  major  part  of  the  an- 
terior semicircle  of  the  pelvis,  we  might,  after  raising  the  shoulder 
and  head  above  the  pubis,  go  immediately  in  search  of  the  feet  or 
knees,  proceeding  along  the  left  side.  Having  got  hold  of  the  legs, 
the  act  of  turning  would  compel  the  head,  which,  besides,  is  already 
repelled  by  the  forearm  within  the  uterus,  to  rise  upwards  and  take 


SHOULDER  POSITIONS.  447 

a  situation  in  the  fundus  of  the  womb.  But  in  this  case  special  care 
should  be  taken  not  to  permit  the  child's  back  to  turn  to  the  poste- 
rior surface  of  the  womb. 

Should  the  shoulder  be  so  disposed  of  that  the  head  were  to  be 
found  above  the  right  sacro-iliac  symphysis,  that  is  to  say,  in  the 
third  position  of  Maygrier,  or  still  nearer  to  the  sacro-vertebral  an- 
gle, the  left  hand,  introduced  in  a  forced  state  of  pronation,  might 
attempt  to  raise  the  shoulder,  and  move  the  head  from  the  right 
sacro-iliac  symphysis  to  a  situation  above  the  left  sacro-iliac  sym- 
physis ;  but  although  this  maneuvre  may  sometimes  be  found  rather 
easier  than  the  former  one,  it  should  be  stated  that  it  is  perhaps  a 
more  dangerous  one  ;  for  provided  the  two  or  three  last  fingers 
should  not  act  with  force  upon  the  occiput  while  the  thumb  and 
index  are  pushing  against  the  upper  part  of  the  chest,  there  is  a  risk 
of  doing  nothing  more  than  effecting  a  retroversion  of  the  head  on 
to  the  back  while  endeavouring  to  displace  it. 

Should  the  membranes  have  been  long  ruptured,  the  womb 
stongly  contracted,  and  the  child  not  to  be  moved  but  with  very 
great  difficulty,  there  is  a  third  maneuvre  that  ought  then  to  be 
preferred,  and  which  perhaps  it  would  be  well  to  employ  in  other 
cases ;  it  consists  in  pushing  the  shoulder  up  with  the  right  hand, 
from  behind  forwards,  as  if  to  make  the  spine  turn  upon  its  own 
axis  ;  then  trying  to  reach  the  right  side  by  passing  along  the  front 
of  the  chest,  while  the  womb  is  forcibly  pushed  backwards  with  the 
left  hand ;  lastly,  in  taking  hold  of  the  feet,  the  right  one  first,  so  as 
to  bring  them  down  in  the  first  position. 

1022.  In  conclusion^  all  the  positions  of  the  left  side  may  be  ma- 
neuvred  with  the  left  hand.  By  not  losing  sight  qf  the  rule  that  the 
thumb  should  always  correspond  to  the  sternal  surface,  the  fingers 
to  the  dorsal  surface,  and  the  cubital  edge  of  the  hand  to  the  child's 
head ;  by  remembering  that  previously  to  going  in  search  of  the 
feet,  the  head  ought  to  be  moved  as  near  as  possible  to  the  left  iliac 
fossa,  the  practitioner  will  be  aware  of  every  thing  that  it  is  essential 
to  know  concerning  the  maneuvre  for  the  left  lateral  surface.  Should 
he  make  use  of  his  right  hand,  as  his  first  object  would  be  to  raise 
up  the  left  shoulder,  so  as  more  readily  to  reach  the  right  shoulder  and 
side,  the  case  would  evidently  be  converted  into  a  right  shoulder 
position,  properly  so  called,  which  I  am  now  about  to  treat  of. 

2.  Positions  of  the  Right  Shoulder. 

1023.  What  I  have  now  said  of  the  left  shoulder  positions  being 
strictly  applicable  to  those  of  the  right  shoulder,  it  would  be  super- 
fluous to  enter  upon  new  details  concerning  the  latter.    I  shall  merely 


448  DYSTOCIA. 

remark,  that  in  the  present  case,  the  right  hand  performs  the  part 
which  was  entrusted  to  the  left  in  the  former  case ;  that  the  head  is 
to  be  moved  towards  the  right  iliac  fossa  previously  to  searching 
further  for  the  feet ;  lastly,  that  the  foetus  should  be  delivered  in  the 
first  and  not  in  the  second  position  of  the  feet.  After  all,  to  save 
the  necessity  of  particular  description,  in  shoulder  positions  it  is 
enough  to  remember  that  the  right  hand  always  goes  to  the  right 
side,  and  the  left  hand  to  the  left  side,  and  that  in  all  cases,  the 
fingers  ought  to  be  situated  in  regard  to  the  foetus  as  has  been 
already  mentioned. 

I  will,  however, observe,  that  these  rules  cannot  be  absolute;  that 
a  knowledge  of  them  merely  renders  the  operation  rather  easier ; 
that  they  may  be  modified  in  a  great  variety  of  ways ;  that  they  are 
principally  established  for  young  physicians  who  are  as  yet  insuffi- 
ciently enlightened  by  experience,  and  who  require  a  certain  number 
of  clues  to  lead  them  through  the  labyrinth  of  practice ;  lastly,  1  will 
state  that  in  cases  where  the  hand  is  carried  into  the  womb  pre- 
viously to  the  rupture  of  the  membranes,  whether  the  child  pre- 
sents with  its  right  side  or  its  left  side,  and  in  any  position  of  the 
shoulder  whatever,  we  may  arrive  at  the  feet  directly,  and  almost 
with  equal  facility  with  either  hand. 

B.  Presentation  of  the  Sternum. 

1024.  The  cephalo-pubic  position  (1st  of  Baudelocque)  of  the 
sternum  might,  rigorously,  be  as  well  reduced  to  the  left  cephalo- 
iliac,  as  to  the  right  cephalo-iliac  position ;  but  it  is  generally  re- 
duced to  the  latter,  because  it  terminates  it  in  the  first  position  of 
the  feet. 

1025.  In  the  right  cephalo-iliac  position  (4th  of  Baudelocque)  the 
right  hand  must  be  made  use  of;  it  is  to  be  introduced  supine  if  the 
head  is  in  front,  prone  if  in  the  contrary  situation,  and  betwixt  these 
two  attitudes,  provided  the  head  be  fairly  to  the  right.  The  part  that 
is  engaged  must  always  be  pushed  back  until  the  trunk  of  the  foetus, 
instead  of  being  convex  on  its  anterior  face,  shall  become  concave ; 
then  the  operator  should  endeavour  to  reach  the  right  shoulder,  be- 
hind which  the  fingers  are  to  be  applied,  while  the  thumb  rests 
on  the  anterior  surface  of  the  thorax  ;  afterwards,  nothing  more  re- 
mains to  be  done  except  to  swing  the  bis-acromial  diameter,  so  that  its 
posterior  extremity  may  turn  downwards,  by  acting  upon  it  as  upon 
a  lever  of  the  first  kind,  whose  fulcrum  is  represented  by  the  thumb, 
and  the  power  by  the  fingers  ;  this  being  done,  the  position  differs 
in  no  respect  from  the  corresponding  one  on  the  right  side,  and  is 
to  be  managed  in  tlie  same  way. 


SHOULDER  PRESENTATIONS.  449 

1026»  In  tii&left  ceplialo-iliac  position  (3d  of  Baudelocque)  the 
left  hand  does  what  the  right  should  do  in  the  opposite  position  ;  it 
pushes  up  the  breast,  gets  hold  of  the  left  shoulder,  draws  it  down 
a  little,  and  if  the  head  were  too  far  from  the  iliac  fossa,  it  brings  it 
nearer  to  it,  obtains  a  dorso-sacral  position  of  the  left  shoulder, 
and  the  rest  of  the  rnaneuvre  presents  nothing  of  a  special  character. 

C.  Presentations  of  the  Back. 

1027.  Right  cephalo-iliac  position.  If  the  head  is  to  the  right, 
in  front,  or  to  the  rear,  in  positions  of  the  back,  the  right  hand  is  to 
be  made  use  of  as  in  positions  of  the  sternum,  and  according  to  the 
same  rules.  Consequently,  it  is  introduced  half  prone,  supine,  or 
more  or  less  completely  prone,  accordingly  as  the  head  looks  to  the 
right,  in  front,  or  to  the  rear ;  but  in  such  a  manner  that  the  thumb 
may  always  pass  in  front  of  the  right  shoulder  and  breast,  while 
the  fingers  rest  upon  the  dorsal  surface.  In  the  first  place,  this 
shoulder  is  to  be  brought  down  so  as, to  make  the  other  rise  ;  it  is 
then  to  be  repelled,  by  acting  on  it  as  upon  the  end  of  a  powerful 
lever,  which  the  thumb  tends  to  move  and  to  oblige  the  foetus  to 
turn  on  its  great  axis,  until  the  position  of  the  back  is  converted 
into  a  corresponding  or  dorso-sacral  position  of  the  right  shoulder. 

This  movement  requires  great  care,,,  for  if  the  bead  does  not  go 
with  the  trunk,  the  cervical  portion  of  the  spinal  marrow  runs 
the  greatest  risk  of  being  lacerated,  or  violently  twisted  in  the 
second  stage  of  the  operation  ;  this  danger  is  to  be  avoided  as  far 
as  possible,  by  pushing  the  chest  very  far  backwards  and  upwards, 
so  as  to  give  great  depth  to  the  curve  of  the  anterior  surface  of  the 
fcEtus  ;  or  if  it  should  be  absolutely  necessary,  by  getting  hold  of  the 
head  itself  to  force  the  face  to  turn  forwards  and  downwards. 
,  1028.  Left  cephalo-iliac  position.  The  left  extremity  of  the  bis- 
acromial  diameter  is  taken  hold  of,  the  fingers  on  the  back,  and  the 
thumb  in  front  of  the  left  shoulder  or  sternum,  and  the  cubital  edge 
turned  towards  the  occiput ;  while  the  trunk  is  turning  on  its  occipito- 
coccygeal  axis,  we  should  endeavour  to  comprise  the  head  in  the 
movement,  and,  if  necessary,  bring  it  near  to  the  iliac  fossa.  In  one 
word,  the  left  hand  here  acts  as  the  right  hand  does  in  the  opposite 
positions ;  it  converts  positions  of  the  back  into  positions  of  the  left 
side,  which  it  afterwards  terminates  by  delivery  in  the  second  posi- 
tion of  the  feet. 
3G 


456  DYSTOCIA. 

SECTION  3. 

Of  the  Maneuvre  in  Presentation  of  the  Pelvis. 

The  maneuvre  in  positions  of  the  pelvis  reduces  itself  in  some  sort 
to  that  of  the  last  stage,  or  stage  of  extraction,  in  the  head  or  trunk 
positions ;  I  need  therefore  only  add  a  few  words  to  what  has  been 
said  farther  back,  in  order  to  conclude  all  that  concerns  it. 

1029.  Although,  strictly  speaking,  the  right  band  might  be  easily 
made  use  of  in  ail  the  positions  which  it  is  proper  to  terminate  by  the 
first  of  the  feet  positions,  and  the  left  only  in  the  opposite  cases,  it 
is,  notwithstanding,  better  to  do  the  very  reverse.  We  can,  with  the 
right  hand,  in  all  the  right  dorso-pelvic  positions,  push  up  one  but- 
tock, or  even  both  of  them  towards  the  right  iliac  fossa,  reduce  inchn- 
ed  to  central  positions,  and  take  hold  of  the  limbs  by  their  anterior  sur- 
faces, withoutieing  obhged  to  assume  an  awkward  attitude ;  whereas 
with  the  left  hand  the  breast  could  not  be  raised  without  difficulty, 
and  it  would  be  still  less  easy  to  reach  the  feet,  if  they  were  not  at 
some  distance  from  the  orifice.  Lastly,  by  using  the  hand  that  cor- 
responds to  that  side  of  the  mother's  pelvis  towards  which  the  child's 
heels  are  to  be  turned,  while  coming  down,  a  half  prone  position  brings 
the  palmar  face  of  the  fingers  in  front  and  on  one  side ;  the  operator 
ia  consequently  in  the  most  favourable  condition  to  prevent  the  back 
of  the  foetus  from  moving  towards  the  sacro-iliac  symphysis,  and  on 
the  contrary,  to  compel  it  to  turn  towards  the  acetabula  ;  the  ope- 
rator can  also  pull  with  all  the  force  that  circumstances  may  require, 
an  advantage  not  to  be  obtained  by  adopting  an  inverse  order  in  the 
apphcation  of  tlie  hand. 

Whenever,  therefore,  it  is  intended  to  deliver  in  the  first  position 
of  the  feet,  that  is,  whenever  the  child's  back  shall  look  more  or  less 
towards  the  left  of  the  pelvis,  or  even  directly  towards  the  pubis  or 
sacrum,  the  left  hand  should  be  introduced  ;  and  the  right  hand  in  all 
the  other  cases. 

A.  Positions  of  the  Feet. 

1030.  Inasmuch  as  the  positions  of  the  feet,  previously  to  the 
rupture  of  the  membranes,  are  scarcely  distinguished  from  those  of 
the  breech,  there  can  hardly  be  any  question  concerning  them  until 
after  this  rupture.  The  accoucheur  then  may  be  called  under  two 
different  circumstances,  which  it  is  important  that  he  should  not  con- 
found with  each  other :  either  the  feet  have  not  cleared  the  vulva, 
or  the  trunk  has  more  or  less  completely  emerged. 


PELVIS  PRESENTATIONS.  45I 

In  the  former  case,  if  the  two  feet  present  together  at  the  orifice  or 
in  the  vagina,  all  he  has  to  do  is  to  take  hold  of  them  and  draw  them 
down  so  as  immediately  to  extend  the  legs,  and  that  the  liips  may  soon 
arrive  at  the  inferior  strait ;  provided  only  one  of  them  can  at  first 
be  found,  some  attempts  should  be  made  to  discover  the  other,  which 
it  is  rarely  difficult  to  do  ;  should  the  attempt  not  succeed,  the  first 
one  should  be  brought  down,  then  secured  by  a  fillet,  and  made  use  of 
as  a  guide  to  the  second,  which  may  perhaps  be  found  reversed  to- 
wards the  breech,  moved  ofi'far  in  a  state  of  abduction,  or  with  the 
leg  and  thii/h  doubled  up  on  the  belly,  &z,c. 

In  the  latter  case,  the  presence  of  the  feet  offers  no  particular 
indication  ;  nothing  is  to  be  done,  as  was  mentioned  in  speaking  of 
turning  in  head  positions,  but  to  pull  the  different  parts  that  are 
still  unexpelled  downwards. 

A  very  necessary  precaution,  when  extracting  a  child  by  the  feet, 
is,  to  act  in  such  a  way  that  at  the  moment  when  the  child  is  passing 
the  straits,  the  occiput  may  look  towards  some  part  of  the  anterior . 
semicircumference  of  the  pelvis.  The  thing  is  easy  ;  and  no  skilful 
practitioner  will  ever  fail  in  bringing  it  about,  when  he  goes  in 
search  of  the  feet  in  a  head  or  trunk  presentation.  But  it  is  no 
longer  the  case  where  the  pelvis  presents  spontaneously  at  the  supe- 
rior strait ;  mistimed  or  unskilful  tractions  may  have  been  instituted 
in  his  absence,  or  when  he  reaches  the  bed-side  of  the  patient  the 
laps  may  have  been  already  expelled  and  the  face  turned  in  front. 
^^'-1031.  The  position  of  the  feet  where  the  child's  dorsal  surface 
looks  backwards  may  give  rise  to  three  particular  cases :  1.  The 
feet  are  still  at  the  superior  strait,  or  in  the  vagina  ;  2,  The  delivery, 
if  left  to  the  natural  powers,  may  be  complicated  with  no  accident? 
or  give  no  evidence  of  requiring  the  assistance  of  the  hand,  until  the 
lower  extremities,  or  even  the  hips  are  born  ;  3.  Turning  has  been 
attempted  on  account  of  some  position  of  the  head  or  trunk,  the 
feet  have  been  brought  down,  but  the  operator  has  failed  to  make 
the  occiput  turn  in  front. 

1032.  Let  us  here  suppose  the  first  hypothesis  :  after  having  got 
hold  of  the  limbs  in  the  manner  heretofore  mentioned,  the  back 
ought  to  be  directed  first  towards  the  sacro -iliac  symphysis  or  iliac 
fossa,  then  towards  the  acetabulum  ;  with  each  pull,  as  the  hfps 
approach  the  perineal  strait,  they  are  taken  in  both  hands,  and  in  the 
interval  betwixt  two  pains  the  whole  trunk  is  pushed  upwards  again, 
as  if  we  wished  to  make  it  mount  up  above  the  superior  strait ;  as 
soon  as  the  womb,  which  is  thus  momentarily  distended,  appears  to 
be  about  to  contract,  the  pelvis  should  be  suddenly  pulled  down, 
while  at  the  same  time  we  endeavour  to  make  the  body  of  the  child 


452  DYSTOCIA. 

revolve  on  its  axis  ;  in  this  way,  says  Baudelocque,  the  cavity  of  the 
womb  is  first  enlarged,  and  as  we  endeavour  in  the  next  place  to 
empty  it  suddenly,  the  organ  is  in  some  measure  surprised,  and  can 
not  contract  so  fast  as  to  prevent  the  head  from  following  the  turn 
we  give  to  the  body.  These  attempts  are  to  be  renewed  from  one 
to  ten  and  even  fifteen  times,  according  to  the  necessity  of  the  case, 
that  is,  until  the  anterior  position  lias  taken  place  of  th(^  posterior 
one,  or  until  the  impossibility  of  effecting  the  change  is  ascertain- 
ed ;  when  the  attempt  proves  successful,  no  particular  difficulties 
remain,  and  the  rest  of  the  maneuvre  is  the  same  as  in  feet  presen- 
tations in  general. 

When  all  hope  of  succeeding  is  abandoned,  we  must  even  be 
resigned  to  let  the  face  come  along  uppermost ;  we  must  redouble 
our  precautions  against  letting  the  chin  depart  from  the  breast ;  the 
arms  should  be  disengaged,  the  hindermost  one  first,  by  pulling  them 
from  behind  forwards,  and  in  a  direction  from  the  head  towards  the 
thorax  ;  immediately  after  this,  two  or  three  fingers  of  each  hand 
should  be  applied  to  the  two  extremes  of  the  occipito-mental  diame- 
ter ;  we  should  endeavour  to  push  the  head  upwards,  or  raise  it  so 
as  to  give  it  more  freedom,  and  finally,  make  it  execute  a  pivot 
movement,  by  which  the  face  is  gradually  carried  backwards. 

Supposing  it  should  be  found  impossible  to  turn  the  occiput  in 
front,  the  shoulders  and  chest  should  be  pulled  downwards,  and 
rather  backwards  than  forwards,  so  as  to  deliver  the  chin,  the  fore- 
head, and  anterior  fontanel  before  the  occiput ;  if  these  tractions 
should  prove  incompetent,  the  forceps  should  be  had  recourse  to. 

1033.  In  the  second  case,  provided  the  head  has  not  as  yet  arrived 
at  the  straits,  we  should  act  as  in  the  first  case,  that  is,  the  foetus 
should  be  pushed  upwards  every  time  we  wish  to  give  the  body  a 
turn  ;  but  we  must  expect  to  succeed  still  more  rarely. 

1034.  In  the  third,  these  attempts  are  of  no  use;  we  may 
neglect  them  altogether,  and  immediately  disengage  the  arms  if  it 
be  not  already  done  ;  we  then  conform,  as  to  the  head,  to  the  prin- 
ciples established  higher  up  :  some  of  the  fingers  must  bo  applied 
to  the  chin,  winch  we  endeavour  to  turn  from  right  to  left,  while 
with  the  other  hand  we  act  on  one  of  the  shoulders  or  the  occiput, 
8o  as  tp  favour  the  complete  rotation  of  the  head  and  trunk,  and 
then  proceed  to  deliver. 

B.  Position  of  the  Breech. 

1035.  As  the  knees  occasion  no  difficulty,  by  their  presentation 
merely,  in  delivering  a  lying-in  woman  ;  as  their  presence  does  not 
at  all  alter  the  principles,  nor  even  the  practical  details  of  the  ma- 


PELVIS  PRESENTATIONS.  453 

iteuvre  ;  as  one  or  more  fingers  are  all  that  is  required  to  disengage 
them,  or  give  them  a  regular  position  when  in  the  vagina;  and 
lastly,  in  as  much  as,  where  this  presentation  does  not  return  into 
the  class  of  breech  presentations,  it  is  always  an  easy  matter  to 
reduce  it  among  the  presentations  of  the  feet,  I  shall  not  devote  a 
special  article  to  the  consideration  of  it,  but  shall  pass  at  once  to 
the  consideration  of  breech  presentations. 

1036.  The  left  hand  should  be  preferred  in  breech  presentations, 
as  in  those  of  the  feet,  whenever  the  back  is  turned  more  or  less  to 
the  left,  and  vice  versa  for  the  right  hand.  The  child  being  doubled 
up,  with  the' thighs- and  legs  raised  up  along  the  abdomen,  if  the 
hips  have  cleared  the  orifice  of  the  womb  and  descended  into  the 
excavation,  or  even  to  the  inferior  strait,  the  groin  that  is  most 
backwards  should  be  hooked  with  a  finger  or  two,  while  the  thumb 
of  the  same  hand  is  appUed  to  the  outer  surface  of  the  anterior  hip. 
If  Any  resistance  is  experienced,  there  will  be  some  advantage  in 
substituting  one  or  two  fingers  of  the  other  hand  for  the  thumb, 
and  if  that  will  not  answer,  the  blunt  hook  should  be  made  use  of. 
As  soon  as  the  hips  have  cleared  the  vulva,  it  is  generally  very  easy 
to  extend  the  Jjmbs,and  the  rest  of  the  process  is  merely  a  footling 
delivery.  '^    '■  •  >   . 

1037.  Previously  to  the  rupture  of  the  membranes,  and  where 
the  breech  is  not  yet  so  far  engaged  as  to  render  it  impossible  to 
push  it  up  again  above  the.  superior  strait,  whether  the  foetus  be 
doubled  up  or  merely  in  a  squatting  attitude,  we  should  always  en- 
deavour to  bring  down  the  feet. 

1038.  In  order  to  push  the  breast  up,  the  hand  is  placed  under  it 
and  along  the  posterior  surface  of  the  thighs  ;  the  thumb  is  placed 
on  the  anterior  and  the  fingers  on  the  posterior  hip  ;  or,  where  the 
fi3etu5  is  still  very  movable  and  very  high  up,  it  is  enough  to  apply 
the  thumb  under  one  of  the  ischia,  and  the  fingers  under  the  other  ; 
the  pelvis  is  then  pushed  towards  the  iliac  fossa  that  corresponds  to 
the  hand  that  is  made  use  of;  then  by  passing  along  on  the  outer 
surface  of  the  limb  that  is  nearest  the  sacrum,  the  feet  may  be  got 
hold  of  and  brought  down,  so  as  to  allow  us  to  embrace  the  fore- 
part of  the  legs  with  the  hand,  and  deliver,  as  in  a  corresponding 
position  of  the  feet ;  that  is,  in  the  first  if  the  left  hand  is  used,  and 
in  the  second  position  if  it  is  the  right  hand. 

1039.  In  conclusion,  the  maneuvre  of  the  pelvis  presents  us  but 
two  particular  indications  :  1.  To  draw  it  down  with  the  fingers  or 
blunt  hooks,  when  it  is  too  low  down  to  be  pushed  back  again  ;  2. 
To  displace  it  whenever  the  thing  is  possible,  so  as  to  let  the  feet 
pass  down  first.     In  both  cases,  when  we  employ  only  one  hand,  the 


454  DYSTOCIA. 

palm  of  which  is  directed  so  as  to  slide  up  along  the  child's  abdo- 
men and  breast,  we  surely  require  for  our  guidance  only  the  follov/- 
ing  rule  ;  that  the  fingers  shall  always  be  applied  to  the  ischium  or 
hip  that  is  opposite^  and  the  thumb  to  the  ischium  or  hip  that  cw- 
responds  to  the  hand  that  is  operating.  Were  the  limbs  found  to 
be  reversed  upon  the  dorsal  surface,  instead  of  being  turned 
towards  the  abdomen,  the  thighs  should  be  acted  on  as  we  do  on 
the  arms,  when  disengaging  them  at  the  inferior  strait;  the 
thumb  fixed  in  the  groin  might  serve  as  a  point  d'appui ;  the 
fingers  being  moved  along  towards  the  ham,  would  represent  the 
power,  and  the  knee  would  be  obliged  to  descend,  drawing  the 
leg  along  with  it.  The  two  limbs  ought  thus  to  be  brought,  either 
together  or  in  succession,  to  their  natural  position.  In  whatsoever 
way  they  may  present,  it  is  always  better  to  make  them  descend 
together,  than  one  by  one  ;  however,  where  too  much  difficulty  is 
experienced,  it  would  be  imprudent  to  persist  in  endeavouring  to 
make  them  descend  simultaneously.  If  one  of  them  should  have 
already  escaped,  the  anterior  one  for  instance,  and  it  should  be  im- 
possible to  get  the  other  one  down,  the  delivery,  in  most  cases, 
would  not  be  rendered  on  that  account  much  more  difficult :  it 
should  be  made  use  of  to  draw  down  by,  while  the  index  and  medius 
fingers,  or  a  blunt  hook,  should  be  applied  to  the  posterior  groin,  as 
has  already  been  mentioned.  If,  on  the  other  hand,  the  anterior 
member  only  should  be  retained  at  the  superior  strait,  it  is  still  more 
important  than  in  the  former  case  to  draw  it  near  the  other  limb,  be- 
cause we  cannot  so  readily  reach  the  groin  in  this  situation,  and  espe- 
cially because  the  action  of  the  blunt  hook  is  not  so  advantageous. 

1040.  Remarks.  In  concluding  this  article,  I  shall  take  the 
liberty  of  again  suggesting  to  students  and  young  accoucheurs,  that 
if,  in  turning  by  the  feet,  they  wish  to  avoid  the  risk  of  often  killing 
the  foetus,  they  ought  never  to  lose  sight  of  the  fact  that  the  head 
cannot  rotate  on  the  spine  more  than  a  quarter  of  a  circle,  without 
luxating  it,  or  straining  the  spinal  marrow  in  a  very  dangerous  way  ; 
that,  in  general,  it  does  not  follow  the  motion  of  the  trunk  of  the 
body,  by  means  of  which  attempts  are  made  to  rotate  it ;  that  it  is 
impossible,  in  any  case,  to  affirm  that  it  has  rotated,  merely  on  the 
ground  that  the  back,  for  example,  has  been  turned  from  behind 
forwards  ;  consequently,  that  in  any  species  of  mancuvre  whatever,  . 
we  should  commit  a  very  great  error  if  we  caused  the  child's  body 
to  turn  more  than  a  quarter  of  a  circle,  without  being  assured  that 
the  head  accompanies  it  in  its  movement. 

1041.  Neither  can  I  leave  this  subject  without  returning  ior  a 
moment  to  the  consideration  of  the  maneuvre  recommended  by 


PELVIS  PRESENTATIONS.  455 

Baudelocque  for  bringing  the  child's  back  in  front,  and  which  was 
spoken  of  some  pages  back.  It  would,  in  my  opinion,  be  wrong  to 
rely  upon  such  attempts.  If  the  womb  is  but  slightly  contracted, 
it  is  useless  to  act  in  that  way  ;  when,  on  the  contrary,  the  foetus  is 
forcibly  compressed,  the  force  which  we  exert  upon  it  from  below 
upwards,  seldom  extends  as  far  as  the  head,  and  even  then  it  cer- 
tainly does  not  change  the  general  disposition  of  the  womb,  so  as  to 
render  the  child  at  all  more  movable.  This  is  not  all :  if  it  be  not 
certain  that  we  shall  be  enabled,  in  this  way,  to  render  the  rotation 
of  the  occiput  easier,  it  seems  to  me  manifest  that  the  abdomen,  the 
thorax,  and  even  the  cervical  portion  of  the  spine  would  not  always 
safely  bear  the  various  kinds  of  pressure  and  the  twists  to  which 
they  will  necessarily  be  subjected  ;  lastly,  to  express  my  unreserved 
opinion,  I  will  Say  that  this  precept  of  Baudelocque  seems  to  me  to 
Jbe  more  the  fruit  of  imagination  than  of  observation,  and  that  mo- 
-'dern  writers  ought,  previously  to  copying  it,  at  least  to  have<called  it 
in  question  and  submitted  it  to  a  new  examination. 

SECTION  4. 
Presentation  of  the  Arm. 

1042.  The  premature  escape  of  the  arm  does  not,  of  itself,  con- 
stitute a  position,  and  forms  only  a  complication  of  other  positions, 
particularly  that  of  the  shoulder.  Both  arms  have  been  seen,  but 
rarely,  to  present  together  at  the  vulva ;  unless  brought  there  by 
inconsiderate  maneuvres,  they  could  not  both  thus  descend  except 
in  back  or  sternum  positions.  It  is  said  that  they  have  been  both 
felt  at  the  orifice  at  the  same  time  with  the  feet,  and  it  is  at  least 
certain  that  they  may  precede  the  head  at  the  inferior  strait ;  so 
that,  although  the  presence  of  the  hand  commonly  indicates  a  posi- 
tion of  the  shoulder,  it  may  also  happen  that  it  is  only  a  complica- 
tion of  a  head  or  pelvis  position. 

1043.  Until  in  the  last  century,  nothing  was  deemed  more  dread- 
ful than  the  appearance  of  the  arm  in  the  course  of  a  labour ;  and 
in  our  day,  the  common  people  still  look  upon  such  an  occurrence 
as  extremely  dangerous.  But  these  fears  are  explained  by  the 
fact,  that  until  the  time  of  Levret  it  was  not  thought  possible  to 
penetrate  into  the  womb  without  having  previously  returned  the 
prolapsed  member  into  its  cavity.  In  reflecting  upon  the  dangers 
occasioned  by  the  ridiculous  or  barbarous  measures  adopted  in  cases 
of  this  kind,  could  it  be  believed  that  physicians  would  have  seriously 
recommended  tliat  a  piece  of  ice  should  be  put  into  the  child's  haild, 


456  DYSTOCIA. 

that  it  should  be  pinched,  or  filHpped,  to  make  it  pull  its  arm  back  I 
Others  have  invented  a  sort  of  forks,  or  crutches,  &c.  to  push  it  up 
with,  by  acting  upon  the  chest ;  the  more  timid  pushed  it  up  to  the 
top  of  the  vagina,  and  sometimes  succeeded  in  returning  it  into  the 
cavity  of  the  womb  ;  but  their  attempts  were  generally  in  vain,  and 
the  arm  if  somewhat  swelled  seemed  to  them  to  constitute  an  insur- 
mountable obstacle  to  the  introduction  of  the  hand  into  the  os  uteri. 
Under  such  circumstances,  the  old  women,  and  even  the  physician 
himself,  could  imagine  no  alternative  save  pulling  at  the  arm  until 
the  child  yielded  and  came  away  doubled,  or  until  the  arm  was  torn 
off.  Pare  advises  that  the  soft  parts  below  the  shoulder  should  be 
first  cut  round,  and  that  we  should  then  resort  to  sharp  pincers  to 
cut  the  bone  with  ;  De  La  Motte  recommends  us  to  twist  the  limb 
round  like  the  limb  of  a  tree  that  we  might  wish  to  tear  off  from 
the  trunk  ;  lastly,  the  most  timid  were  satisfied  with  making  deep 
scarifications  in  the  tumefied  part,  so  as  to  lessen  its  size. 

Happily,  at  the  age  in  which  we  live,  such  a  dreadful  doctrine  is 
held  by  nobody.  Baudelocque  and  his  successors  did  it  justice  long 
ago  ;  and  at  present  it  is  not  without  a  sentiment  of  indignation,  that 
we  still  hear  from  time  to  time  of  practitioners  who  dare  to  conform  to 
it  in  practice.  I  should  not  even  insist  upon  this  point,  had  not  certain 
persons  had  the  inconceivable  audacity  to  renew  this  revolting  prac- 
tice of  late  years,  in  Bretagne,  Normandy,  Champagne,  and  even 
in  the  environs  of  Montpellier,  almost  at  the  same  time  ;  particu- 
larly, had  not  these  practitioners  found  some  defenders  in  the  capital ; 
had  not  certain  persons  had  the  hardihood  to  publish,  in  1826, 
1827  and  1828,  various  pamphlets  to  justify  a  conduct  so  far  re- 
moved from  tokological  doctrines,  and  had  they  not  anew  appealed 
to  the  authority  of  A.  Pare,  Mauriceau,  Deventer,  De  La  Motte, 
Puzos,  Mesnard,  Levret,  &,c.  as  if  the  modern  accoucheurs  had  not 
overturned  without  exception  all  the  reasons  advanced  by  their  pre- 
decessors in  favour  of  the  amputation,  or  tearing  off  of  the  arms! 

1044.  I  do  not  intend  to  deny  that  it  never  has  been  necessary 
to  separate  from  the  trunk  a  member  prematurely  escaped,  in 
order  to  penetrate  more  readily  into  the  womb  ;  I  merely  assert  that 
I  cannot  conceive  of  such  a  necessity  ;  that  it  is  impossible  to  admit 
of  if,  except  where  the  child  is  dead  ;  that  no  matter  how  much  the 
arm  may  be  infiltrated  or  swollen,  a  skilful  accoucheur  will  always 
be  able  to  carry  his  hand  into  the  womb  without  mutilating  any 
thing  ;  lastly,  that  without  being  able  to  say  how  far  the  Norman 
surgeon  may  have  departed  from  sound  rules,  we  must  at  least 
admit,  that  the  reasons  and  proofs  cited  by  M.  Roux  for  his  excuse 
would  be  dangerous  if  taken  in  the  very  letter. 


ARM  PRESENTATIONS.  457 

1046.  In  order  that  delivery  may  be  efFetted,  the  child's  head 
miist  pass  through  the  os  uteri :  but  the  hand  of  the  physician  arid 
the  arm  of  the  child  can  never  be  equal  in  size  to  the  volume  of  the 
child's  head.  Therefore,  the  presence  of  an  arm  is  incapable  of 
preventing  the  hand  from  passing  into  the  uterus,  even  although 
there  should  be  infiltration  and  tumefaction  of  the  labia  ;  and  after  , 
that,  it  becomes  completely  useless  to  teturn  the  arm  previously  to 
going  in  search  of  the  feet. 

Therefore,  when  d  hand  appears  at  the  vulva,  and  it  is  impos- 
sible to  ascertain  certainly  that  the  corresponding  shoulder  is  at  the 
superior  strait,  far  from  becoming  alarmed,  and  pushing  it  back,  it 
is,  on  the  contrary,  best  to  secure  it  with  a  fillet ;  the  fillet  being 
fixed,  the  shoulder  is  next  pushed  up,  and  we  proceed  to  get  hold  of 
the  feet,  just  as  if  there  were  no  complication  whatever.  As  we 
draw  the  lower  extremities  downwards,  the  arm  mounts  upwards, 
and  the  fillet  serves  to  pull  it  along  at  the  same  time  with  the  feet, 
after  the  version  is  complete. 

.  1046.  Although  the  descent  of  the  arm  along  with  the  head  is  not 
a  serious  cause  of  dystocia,  there  are,  notwithstanding,  cases  where 
the  course  of  the  labour  is  really  embarrassed  by  such  an  occur- 
rence. Consequently,  w'e  may  get  rid  of  the  complication  if  pbs- 
siblei  If  called  before  the  superior  strait  has  been  passed,  there  is 
no  difficulty  in  returning  the  child's  hand  into  the  uterus,  and  re- 
taining it  there  by  means  of  a  few  fingers  until  the  head  is  well 
engaged.  If  called  at  a  later  period,  great  difficulties  are  sometimes 
experienced;  in  some  instances  the  thing  is  impossible;  we  must, 
under  such  circumstances,  endeavour  to  make  the  hand  slip  along 
the  forehead  towards  the  sacro-iliac  symphysis  or  obturator  foramen 
of  the  side  where  there  is  the  least  pressure ;  but  should  some  new 
difficulty  otise,  rendering  the  immediate  termination  of  the  labour 
necessary,  the  forceps  would  be  applied,  without  regard  to  the  pre- 
sence of  the  arm. 

In  case  the  hands  should  present  at  the  same  time  with  the  feet, 
they  doubtless  would  not  long  maintain  their  position ;  the  contrac- 
tions of  the  womb  would  soon  force  them  to  rise,  by  urging  the 
breech  down.  Besides,  in  order  to  obviate  all  cause  of  alarm,  it 
would  be  merely  necessary  not  to  confound  them  with  the  lower 
extremities,  and  to  pull  upon  the  latter  until  the  hips  had  come 
down.  ' 

Pean  and  Deleurye  have  advised,  where  an  arm  and  shoulder 

fill  up  the  orifice  too  exactly  to  allow  the  hand  to  reach  the  child's 

foot,  that  we  should  begin  by  bringing  down  the  other  arm,  so  as  to 

enable  us  to  penetrate  more  easily  into  the  womb.     This  precept 

3H 


458  DYSTOCIA. 

has  been  the  object  of  much  criticism :  it  has  been  said  that  two 
arms  must  necessarily  occupy  more  space  than  a  single  one  ;  that  by 
bringing  a  second  one  alongside  of  the  first,  instead  of  overcoming 
the  obstacles,  we  should  only  increase  them  ;  and  that,  if  the  hand 
may  be  carried  up  as  far  as  to  the  arm  that  has  not  yet  escaped,  there 
is  no  reason  why  it  could  not  reach  to  the  feet  themselves. 

I  have  had  no  occasion  to  repeat  the  practice  of  Deleurye  in  this 
respect ;  nevertheless,  it  seems  to  me  to  have  been  proscribed  pre- 
viously to  being  sufficiently  examined.  Baudelocque  is,  assuredly, 
deceived,  when  he  maintains  that  it  is  always  as  easy  to  reach  the 
feet  as  the  arm  that  is  still  retained  above  the  orifice  of  the  womb ; 
the  arm  may  be  near  enough  to  be  seized  with  two  or  three  fingers, 
whilst  the  feet  always  require  the  whole  hand  to  be  introduced,  and 
most  commonly  to  a  great  depth.  By  pulling  upon  the  second  arm 
we  tend  to  make  the  engaged  shoulder  mount  upwards,  and  to  con- 
vert a  position  of  the  lateral  surface  into  one  of  the  sternal  surface, 
or  dorsal  surface,  and  I  can  conceive  that  in  some  cases  there  would 
result  an  increased  facility  of  passing  the  hand  and  of  performing  the 
remainder  t)f  the  maneuvre. 

But  what  shall  I  say  of  Dr  Davis,  who  recommends  us  in  certain 
cases  of  arm  presentation  to  terminate  the  delivery  by  means  of 
embryotomy  !  of  Douglas,  and  of  Sims,  who  profess  the  same  senti- 
ment ;  and  above  all,  of  Dr  Lee,  who,  to  spare  the  mother,  separates 
the  arm  from  Hie  hody^  perforates  the  thorax^  fixes  a  crotchet  upon 
the  pelvis  or  inferior  part  of  the  fatal  spine,  and  by  means  of  suffi- 
cient force  thus  extracts  the  child !  as  if  this  operation  were  not  an 
hundred  times  more  dangerous,  even  for  the  woman,  than  the  most 
painful  and  complicated  version  !  Who  shall  say  how  far  the  teme- 
rity of  certain  persons  shall  carry  them  ?  Has  not  a  surgeon  in  one 
of  the  colonies  lately  had  the  hardihood  to  perform  the  hypogastric 
cesarian  operation  simply  because  turning  appeared  to  him  to  be 
too  difficult  in  an  arm  pre3entation,and  what  is  still  more  surprising, 
to  boast  of  his  conduct,  as  a  model  to  be  followed  ?  It  is  only  by 
remembering,  that,  in  the  sciences,  where  men  are  always  to  be 
found  who  invariably  substitute  for  the  bounds  of  the  possible  the 
limits  of  their  own  knowledge  and  capacity,  that  we  are  enabled  to 
conceive  of  such  scandalous  practices. 

As  long  as  the  accoucheur  is  not  in  possession  of  certain  proof 
of  the  child's  death,  he  has  no  right,  under  any  pretext,  to  mutilate 
it ;  and  if  ever  the  presence  of  the  arm  could  really  prevent  the  in- 
tromission of  the  physician's  hand,  it  would  be  far  better  to  follow  the 
advice  of  Bodin,  and  perform  the  vaginal  cesarian  operation,  than 
to  have  recourse  to  embryotomy.    Even  although  the  child  be  dead. 


TURNING.  459 

we  should  proceed  in  the  same  manner,  and,  in  the  first  place,  put 
in  requisition  blood-letting,  the  bath,  injections,  ointments,  indeed 
all  sorts  of  relaxing  and  sedative  measures. 

General  Recapitulation  on  the  Maneuvre. 

1047.  In  the  maneuvre,  aU  the  positions  of  the  head  may  he  re- 
duced to  two;  all  the  positions  of  the  side  belong  to  the  second  stage 
of  the  maneuvre  for  the  head  positions  ;  all  the  positions  of  the  back 
and  of  the  sternum  should  be  reduced  to  shoulder  positions;  and  all 
positions  of  the  shoulder  are  at  first  converted  into  positions  of  the 
feet.  In  turning,  therefore,  there  are,  in  fact,  but  two  positions 
which  it  is  essential  to  study  profoundly,  and  consequently  but  two 
maneuvres  which  it  is  indispensable  to  know  well  :  further,  as  these 
two  maneuvres  differ  only  in  requiring  the  employment  of  A  differ- 
ent hand,  as  in  reality  the  right  hand  does  not  maneuvre  differently 
from  the  left,  it  follows  that  the  whole  maneuvre  in  Jabours  is  re- 
duced to  the  rules  which  were  laid  down  in  speaking  of  version  by 
the  feet  in  positions  of  the  vertex.  I  am  aware  that,  as  thus  pro- 
posed, the  question  will  not  be  always  exactly  understood  ;  but  I  also 
doubt  whether  those  to  whom  these  general  rules  will  not  suffice, 
Ivill  be  able  to  make  much  out  of  the  most  elaborate  explana- 
tions. In  the  detailed  applications  there  are  an  infinity  of  shades 
which  words  cannot  describe,  but  which  are  easily  guessed  at  by  an 
intelligent  man,  or  which  practice  alone  may  teach  him  to  discrimi- 
nate. 


ARTICLE  II. 
Of  the  Forceps. 

SECTION  1. 

The  Forceps  in  itself  considered. 

1048.  The  forceps  is  an  instrument  with  which  the  child,  while 
still  within  the  organs  of  the  mother,  is  seized  and  drawn  forth.  It 
is  not  very  precisely  known  who  was  the  first  inventor  of  this  sort 
of  pincers,  nor  at  what  period  it  was  first  made  mention  of.  It  is 
true  that  in  the  time  of  Avicenna  certain  blades  with  teeth  in  them 
were  made  use  of  for  the  extraction  of  the  dead  fcetus  ;  Rueff  also 
speaks  of  a  pincers  he  made  use  of  to  extract  the  separate  bones  of 


460  THE  FORCEPS. 

the  cranium  ;  but  what  comparison  is  there  between  these  clumsy 
instruments,  which  no  one  would  have  ventured  to  apply  to  a  living 
child,  and  the  forceps  employed  at  the  present  day  ? 

|049.  The  Chamberlains  were  for  a  long  time  in  possession  of  a 
secret  for  terminating  difficult  labours.  One  of  the  members  of 
that  family  came  to  Paris  for  the  purpose  of  convincing  the  French 
of  the  value  of  his  instrument ;  but  as  he  was  not  successful  in  his 
first  attempts,  and  was  ill  satisfied  with  his  reception  in  Frartce,  he 
returned  with  his  secret  to  London.  Chapman  and  GiflTard,  who  pre- 
tend to  have  been  acquainted  with  the  means  employed  by  Cham- 
berlain, published  a  description  of  it  at  the  commencement  of  the 
eighteenth  century,  and  asserted  that  it  consisted  of  a  forceps  for 
taking  hold  of  the  head  with  ;  a  surgeon  of  Brentford,  whose  name 
was  Drinkwater,  is  also  spoken  of  as  the  author  of  a  similar  for- 
ceps ;  but  it  is  really  impossible  to  determine  whether  the  Cham- 
berlains made  use  of  a  forceps  or  a  lever,  or  some  other  instru- 
ment, nor  wJiether  the  hands,  which  Palfyn  says  he  first  thought  of, 
and  the  invention  of  which  was  claimed  by  Ledoux,  were  any  thing 
else  than  the  instrument  used  in  England. 

J050.  However  this  may  be,  it  was  about  this  time  that  the  use 
of  the  forceps  was  introduced  into  the  practice  of  midwifery.  At 
first,  formed  of  two  blades,  either  full  or  fenestrated,  which  were  in- 
troduced separately  into  the  pelvis,  and  which  were  but  slightly 
curved,  they  soon  received  the  addition  of  a  double  notch,  to  admit 
of  their  being  crossed.  Smellie  made  them  an  extremely  simple 
instrument,  the  application  of  which  is  as  easy  as  possible;  this 
accoucheur  even  thought  it  would  be  well  to  have  two  forceps,  one 
very  short,  to  be  applied  to  the  head  when  already  down  in  the  ex- 
cavation, and  the  other  rather  longer,  having  a  concave  edge,  for 
the  purpose  of  penetrating  as  far  as  the  superior  strait. 

Levret,  on  his  part,  introduced  such  important  modifications  of 
the  forceps,  that  he  in  some  sort  made  a  new  instrument  of  it, 
which  is  still  known  in  the  science  as  LevreVs  forceps.  Like  all 
the  others  this  forceps  is  composed  of  two  branches  :  one  called  the 
male  branch,  which  I  prefer  to  call  the  left  branch,  and  the  other  the 
female  branch,  which  1  shall  call  the  right  branch  ;  the  blade  of  each 
is  largely  fenestrated,  has  a  bead  or  blunt  crest  on  tlie  circumfer- 
ence of  its  concave  surface,  and  on  one  of  its  edges  exhibits  a 
curve  which  corresponds  with  the  curve  of  the  axes  of  the  pelvis. 
The  handles,  which  are  entirely  metallic,  and  not  quite  so  long  as 
the  blades,  terminate  by  a  flattened  hook.  At  the  place  where  they 
cross  there  is  a  flat  surface,  a  pivot  and  a  mortise,  which  admit  of 


THE  FORCEPS.  461 

their  being  firmly  united,  and  prevent  them  from  sliding  on  each 
other  when  they  are  once  applied. 

1031.  Since  the  time  of  Levret  and  Smellie  the  forceps  has  un- 
dergone numerous  changes,  without  speaking  of  those  of  Roederer, 
Crantz,  Walbaum,  Johnson,  Fried,  Stein,  Leake,  Pienck,  and  an 
infinity  of  others,  the  figures  of  which  maybe  seen  in  the  treatise  of 
Muller.  We  have  the  jointed  forceps  of  Saxtorph,  which  in  other 
respects  very  closely  resembles  Smellie's  instrument ;  that  of  Cou- 
touly,  also  jointed,  but  at  the  same  time  much  more  complex  than 
the  former,  and  which  admits  of  various  shaped  blades  being  fixed 
to  the  same  handle,  according  to  circumstances  ;  another  one,  by  the 
same  accoucheur,  for  the  handle  of  which  there  is  substituted  a  trans- 
verse metallic  hilt,  and  which,  in  consequence  of  the  manner  in  which 
the  branches  are  united,  must  act  like  a  lever  of  the  third  kind  ;  that 
of  Baudelocque,  or  Pean,  which  differs  from  Levret's  only  in  being 
rather  longer ;  the  forceps  of  Thenance,  the  branches  of  which  need 
not  be  crossed,  and  which  unite  near  to  the  curved  end  of  the  han- 
dle, and  is  thus  converted  into  a  lever  of  the  third  kind,  like  one  of 
those  of  Coutouly.  The  two  forceps  of  M.  Dubois  ;  that  of  Brula- 
tour,  jointed  by  a  peculiar  mechanism  ;  that  of  Bruninghausen,  the 
pivot. of  which  is  replaced  by  asort  of  round-headed  nail,  and  with 
very  small  fenestres  in  the  blades ;  then  the  forceps  of  Meryen,  which 
is  also  jointed;  then  that  of  doctor  Guillon,  also  jointed,  and  which 
has  no  need  of  a  movable  pivot  in  order  to  be  united,  and  contains 
in  its  handle  a  pelvi-cephalometer,  blunt  hooks,  sharp  crotchets,  a 
perforator,  and  an  extractor.  Lastly,  MM.  Capuron,  Maygrier, 
Flamant,  Colombat,  and  Prout  have  also  thought  proper  to  propose 
some  modifications  in  the  construction  of  the  forceps,  so  that  the 
profession  is  now  in  the  possession  of  near  an  hundred  species. 

1062.  There  is  not,  strictly  speaking,  one  of  these  forceps  with; 
which  the  principal  object  proposed,  viz.  the  extraction  of  the 
foetus,  cannot  be  attained  ;  but  at  the  same  time,  not  one  of  them 
presents  more  real  advantages  united  than  Levret's.  Its  inventor, 
who  applied  it  so  ofleny  Baudelocque,  whose  practice  was  so  exten- 
sive, Mesdames  Lachapelle  and  Boivin,  who  must  have  assisted  the 
delivery  of  so  many  women,  MM.  Desormeaux,  Gardien,  Evrat, 
&c-  never  felt  the  necessity  for  modifying  Levret's  forceps,  and  M. 
Dubois  himself  has  long  since  rejected  in  his  own  practice  several 
alterations  in  them  introduced  by  himself. 

It  is  well  to  remark,  besides,  that  most  of  these  pretended  im- 
provements have  been  proposed  only  by  young  men,  who  had  had 
no  opportunity  of  convincing  themselves  that  in  this,  as  in  all  other 
surgical  operations,  much  less  reliance  is  to  be  placed  upon  the 


462  THE  FORCEPS. 

form  of  the  instrument  than  upon  the  address  or  skill  of  the  ope- 
rator. 

1063.  The  Levret  forceps,  made  somewhat  larger,  according  to 
the  views  of  Pean,  deprived  of  the  bead  upon  its  concave  surface, 
and  file-polished,  in  the  way  directed  by  Professor  Flamant,  termi- 
nating in  blunt  hooks,  containing  a  pique,  as  recommended  by 
M.  Dubois,  without  any  shoulder  near  the  joint,  and  without  a 
sliding  plate  to  secure  the  pivot,  is  the  one  I  prefer.  A  correction 
that  I  would  willingly  adopt,  provided  it  could  be  effected  without 
weakening  the  instrument,  would  consist  in  having  hinged  joints,  so 
as  to  permit  them  to  be  doubled  up,  and  thus  rendered  more  port- 
able ;  but  up  to  the  present  time  this  has  been  attempted  in  vain, 
and  an  examination  of  the  forceps  lately  made  by  M.  Colombat, 
leads  me  to  think  that  that  ingenious  surgeon  will  not  be  more  for- 
tunate in  this  respect  than  his  predecessors. 


SECTION  2. 
Of  the  Use  of  the  Forceps. 

1.  The  cases  that  require  the  employment  of  the  forceps  are  nu- 
merous, and  may  be  divided  into  two  classes  :  in  the  one,  no  other 
means  except  the  forceps  can  be  had  recourse  to  ;  in  the  other,  it 
would,  strictly  speaking,  be  possible  to  have  recourse  to  turning,  or 
to  rely  upon  some  other  means  of  succour,  should  it  be  desirable  to 
avoid  applying  the  forceps.  Antecedently  to  the  invention  of  this 
instrument,  all  those  labours  that  could  not  be  terminated  by  the  liand 
alone,  were  treated  by  embryotomy,  or  by  some  serious  operation 
upon  the  mother  ;  at  present  we  are  rarely  reduced  to  the  necessity 
of  thus  sacrificing  the  child,  and  of  equally  compromitting  the  safety 
of  the  mother,  because  the  forceps  generally  suffices  to  obviate  this 
destructive  practice. 

1054.  It  has  been  laid  down  as  a  general  rule  that  the  forceps 
must  be  applied,  1.  Whenever  the  head  is  too  large,  cither  relatively, 
or  absolutely,  to  pass  through  the  passages  without  exposing  the 
woman  to  the  hazard  of  exhaustion,  or  other  dangers  ;  2.  When  the 
womb  is  in  a  state  of  inertia,  and  efforts  to  restore  its  contractility 
prove  to  be  in  vain,  and  the  head  is  found  to  bo  so  far  engaged  that 
it  is  impossible  to  restore  it  to  the  superior  strait ;  3.  When  any 
accident  renders  the  extraction  of  the  foetus  indispensable,  and  the 
bead  has  already  descended  into  the  excavation.  . ' 

1056.  Too  large  a  head.  If,  as  is  already  proved  by  the  expe- 
riments of  Baudelocque  and  some  other  authors,  the  head  of  a  new 


USE  OF  THE  FORCEPS.  463 

born  chHd,  when  squeezed  so  as  to  bend  a  forceps  of  the  best  con- 
struction, is  reduced  in  diameter  not  more  than  three  or  four  lines 
at  the  utmost,  it  is  evident  that  when  taken  bold  of  within  the  pelvis, 
where  it  is  already  more  or  less  compressed  in  various  directions,  it 
would  not  be  prudent  to  depend  upon  any  greater  degree  of  re- 
duction ;  and  besides,  to  obtain  a  reduction  to  that  amount,  it  would 
be  necessary  for  the  instrument  to  be  applied  exactly  to  the  two  ex- 
tremes of  the  bi-parietal  diameter.  But  when  we  come  to  reflect 
upon  the  difficulty  of  fixing  the  blades  exactly  upon  the  points  de- 
sired, and  that  each  of  them  arc  a  line  and  a  half  in  thickness,  it  is 
difficult  to  believe  that  a  head  too  large  to  pass  through  the  pelvis 
under  the  influence  of  the  powerful  contractions  of  the  womb  and 
the  well  directed  eflTorts  of  the  woman,  could  derive  any  great  assign 
tance  from  the  application  of  the  forceps. 

1066.  Weakness  of  the  organism.  Inertia,  or  want  of  contrac- 
tions of  the  womb,  is  one  of  the  cases  for  which  the  forceps  is  most 
frequently  applied.  When  the  head  passes  with  difficulty  through 
the  straits,  and  the  woman  is  exhausted  with  vain  effiDrts,  the  efficacy 
of  this  instrument  is  not  contested  by  any  one  ;  but  this  is  not  the 
case  where  there  is  inertia  only,  without  any  narrowness  of  the  pas- 
sages. Here  every  thing  should  be  tried  with  a  view  of  restoring 
the  action  of  the  womb,  and  the  forceps  ought  not  to  be  made  use 
of  until  after  the  ergot  has  been  tried  in  suitable  doses. 

1057.  Accidents.  When  the  child  presents  by  the  vertex  or  by 
the  face,  and  one  of  the  complications  pointed  out  in  another  article 
renders  it  necessary  to  deliver  the  woman  without  delay,  one  of  the 
two  following  conditions  will  necessarily  exist :  1 ,  The  membranes 
have  been  ruptured  and  the  waters  discharged  for  a  long  time  ;  the 
womb  is  strongly  applied  to  the  foetus,  and  the  head  has  reached 
the  excavation,  or  it  is  at  least  pretty  firmly  engaged  in  the  superior 
strait ;  in  which  case  nothing  can  supply  the  place  of  the  forceps ; 
2.  The  OS  uteri  is  dilated,  the  head  is  engaging,  the  membranes  are 
ruptured  :  strictly,  the  forceps  might  be  applied ;  but  the  child  is 
still  sufficiently  movable  to  admit  of  our  going  in  search  of  its  feet. 
In  this  case  practitioners  are  not  agreed  as  to  the  best  mode  of  pro- 
ceeding ;  some  think,  with  Levret,  Smellie,  Plenck,  and  especially 
with  M.  Flaraant,  that  the  forceps  promises  greater  advantages  than 
turning ;  others,  along  with  Madame  Lachapelle,  M.  Desormeaux, 
and  almost  all  the  modern  practitioners,  are  of  a  contrary  opinion. 
I  think  there  is  error  and  reason  on  both  sides.  M.  Flamant  speaks 
the  truth  when  he  maintains  that  the  forceps  is  much  less  dangerous 
for  the  foetus  than  turning  by  the  feet,  and  that  it  is  to  be  preferred 
in  all  cases  where  too  much  difficulty  does  not  arise  in  its  applica- 


464  USE  OF  THE  FORCEPS. 

tion ;  but  he  relies  too  much  upon  his  personal  address,  and  certainly 
inculcates  a  dangerous  principle  when  he  affirms  that  turning  and 
delivering  the  child  by  the  feet  is  almost  never  necessary ;  and  that» 
however  movable  and  high  up  above  the  abdominal  strait  the  head 
may  be,  the  forceps  is  always  to  be  preferred. 

1068.  Every  accoucheur  knows  that  if  the  head  is  still  movable, 
it  will  displace  itself  during  the  introduction  of  each  branch  of  the 
forceps,  and  most  generally  is  difficult  to  get  hold  of;  that  as  the 
blades  of  the  instrument  cannot  in  reaching  it  be  accompanied  by 
the  fingers,  unless,  as  is  M.  Flamant's  practice,  the  whole  hand  is  in- 
troduced into  the  pelvis,  they  are  in  some  measure  introduced  at 
hap-hazard  into  the  uterine  cavity  ;  that  it  is  most  generally  impossi-* 
ble  to  say,  exactly,  whether  they  embrace  the  occipito-frontal  diame- 
ter, rather  than  any  other  ;  finally,  that  the  woman  is  exposed  to  a 
thousand  dangers,  whereas  the  feet  may  be  brought  down  with  far 
less  difficulty,  and  at  a  much  smaller  risk  of  accidents ;  but  it  is 
also  undeniable,  and  it  appears  to  be  too  much  overlooked  at  the 
present  day,  that  although  the  woman  runs  incomparably  less  risk  in 
turning,  the  same  is  not  true  as  to  the  child,  which  too  frequently 
becomes  the  victim  of  this  maneuvre,  while  it  scarcely  suffers  at  all 
under  the  methodical  application  of  the  forceps. 

1059.  It  is  therefore  wisest  to  pursue  a  just  medium  betwixt  these 
two  extremes,  to  prefer  the  forceps,  when  we  are  much  accustomed 
to  handle  them,  when  they  can  be  applied  without  too  much  diffi- 
culty, and  without  any  fear  of  injuring  the  woman  ;  on  the  con- 
trary, to  have  recourse  to  the  hand  to  draw  down  the  feet,  under 
the  opposite  circumstances,  that  is  to  say,  when  the  head  is  too  high 
up,  or  too  movable  to  be  easily  got  hold  of,  and  where  there  is  noth- 
ing to  prevent  the  artificial  evolution  of  the  foetus. 

2.  Tlie forceps  should  only  he  applied  to  the  head  of  the  fatus  ; 
Smellie  and  others  were  wrong  to  advise  their  being  applied  upon 
the  foetal  pelvis  ;  for  should  even  a  small  amount  of  force  be  em- 
ployed, they  would  crush  the  bones  of  the  hips ;  the  upper  ends  of 
the  blades  would  contuse  or  lacerate  the  abdominal  viscera,  and  in- 
evitably kill  the  child  ;  besides,  the  blunt  hook  or  fingers  would 
always  advantageously  supply  their  place  here  ;  the  head  is  the  only 
part  upon  which  it  can  act  or  be  placed  without  inconvenience,  and 
for  which  it  was  constructed. 

1060.  From  Levret  and  Smellie  down  to  the  most  modern  ac- 
coucheurs, the  French  and  English  authors  have  all  recommended 
that  the  forceps  should  be  applied  so  that  its  two  claws  should  cover 
the  two  extremes  of  the  bi-parietal  diameter;  that  its  long  axis  should 
be  parallel  to  the  occipito-mental  diameter,  and  its  concave  cdge» 


USE  OF  THE  FORCEPS.  465 

turned  towards  the  occiput,  excepting  always  those  cases  where  the 
head  is  delivered  in  an  occipito- posterior  position  ;  it  is  true,  that  De- 
leurye  and  Baudelocque  had  admitted  that  where  the  head  is  locked 
transversely  at  the  superior  strait,  it  might  at  first  be  grasped  by  the 
occiput  and  forehead,  so  as  to  make  it  descend  into  the  excavation, 
to  be  afterwards  laid  hold  of  in  a  more  advantageous  manner  ;  but  as 
far  as  I  know,  no  body  has  followed  this  advice,  especially  as  the 
case  supposed  by  Baudelocque  has,  perhaps,  never  occurred. 

1061.  The  practitioners  of  Germany,  Prussia,  and  Russia,  fol- 
low quite  a  different  rule ;  they  pay  no  regard  to  the  position  oi 
the  head  ;  the  pelvis  alone  guides  them  ;  according  to  them,  if  the 
convex  edges  of  the  blades  look  towards  the  iliac  fossse,  they  are 
well  placed  ;  the  reason  they  assign  is  that  we  can  very  rarely  be- 
forehand determine  what  is  the  exact  situation  of  the  occiput ; 
that  even  supposing  we  could  ascertain  it,  it  would  not  on  that  ac- 
count be  necessary  to  change  the  mode  of  application  of  the  instru- 
ment, inasmuch  as,  in  the  diagonal  positions,  the  mere  power  exert- 
ed in  fixing  and  uniting  the  blades  brings  the  forehead  in  front  of 
the  sacrum  or  behind  the  pubis ;  that  completely  transverse  posi- 
tions are  exceedingly  rare,  and  would  render  the  application  of  the 
forceps  too  difBcult,  if  the  design  of  embracing  the  parietal  pro- 
tuberances were  obstinately  persisted  in  ;  lastly,  that  by  conforming 
to  their  doctrine  the  operation  is  always  extremely  simple,  and  that 
the  head  almost  always  ends  by  placing  itself,  if  it  were  not  so 
already,  in  an  antero-posterior  position  ;  so  that,  afler  all,  the  same 
result  is  obtained,  only,  by  conforming  to  the  principles  generally 
adopted  among  us. 

1062.  Without  denying  that  there  may  be  somewhat  of  truth  in 
this  view  of  the  subject,  which,  it  seems  to  me,  has  not  been  suffi- 
ciently attended  to  by  the  French,  it  may,  nevertheless,  be  objected, 
that  as  a  general  proposition,  it  will  always  be  better  to  pass  the 
blades  of  the  forceps  immediately  upon  the  temporo-parietal  regions 
of  the  head,  than  always  to  introduce  them  along  the  sides  of  the 
pelvic  cavity ;  that  if  it  is  rare  to  find  the  head  situated  directly  across 
the  pelvis,  it  is  at  least  common  to  find  it  turned  towards  one  of  the 
acetabula,  or  sacro-iliac  symphyses  ;  that  it  is  not  only  good,  under 
such  circumstances,  to  have  the  forceps  turned  somewhat  to  the 
right  or  lefl ;  but  also,  that  it  most  commonly  assumes  that  direction' 
spontaneously ;  and,  so  to  speak,  in  spite  of  the  Operator,  provided 
the  head  be  pretty  firmly  fixed  in  the  passage.  Let  us  observe,  fur- 
ther, that  by  grasping  the  two  ends  of  the  occipijp-ffon^tal  diameter, 
the  head  is  prevented  from  flexing ;  it  is  forced  to  descend  trans- 
versely, to  present  one  of  its  longest  diameters  tp  the  different  pas- 

3  1 


i^  USE  OF  THE  FORCEPS. 

i 

sages,  and  that  if  taken  hold  of  in  this  situation,  it  cannot  pass  through 
the  inferior  strait. 

1063.  To  conclude,  inasmuch  as  the  occipito-bregmatic  and 
occipito-frontal  diameters  always  turn  more  or  less  directly  from 
front  to  rear  when  they  reach  the  excavation  ;  as  in  cases  where  the 
head  has  not  yet  cleared  the  superior  strait,  the  occiput  or  forehead 
almost  always  looks  towards  one  of  the  cotyloid  cavities ;  as  the 
clams  of  the  forceps,  after  their  introduction,  naturally  incline  to- 
wards the  sides  of  the  head,  or,  when  it  opposes  but  httle  resistance 
to  the  force  exerted  upon  it,  cause  it  to  turn  on  its  vertical  axis,  it 
may  be  said  that,  the  difference  between  our  practice  and  that  of  the 
Germans  is  greater  in  appearance  than  in  reality,  and  that,  in  fact, 
it  does  not  appear  that  it  can  ever  be  indispensably  necessary  to 
place  one  of  the  branches  of  the  instrument  in  front  and  the  other 
behind. 

1064.  Thus  the  forceps  may  be  applied  to  the  head  when  the 
vertex  or  the  forehead  comes  first,  and  even  when  the  trunk  escapes 
before  the  head. 

To  render  this  application  indispensable,  it  is  necessary :  1 .  That 
the  head  shall  not  require  to  be  reduced  more  than  two  or  three 
lines,  or  that  it  shall  be  possible  to  displace  it,  and  direct  it  more 
advantageously  through  the  straits  ;  2.  That  there  shall  be  a  press- 
ing need  for  terminating  the  labour  without  delay,  or  that  no  further 
reliance  can  be  placed  on  the  powers  of  the  woman  in  the  expulsion 
of  the  child  ;  3.  That  the  head  shall  be  engaged  so  far  that  it  would 
be  impossible  without  difficulty  to  return  it  and  proceed  in  search 
of  the  feet;  4.  That  the  membranes  shall  have  been  ruptured  and 
the  OS  uteri  completely  dilated  for  a  greater  or  less  period  of  time. 

1065.  Previously  to  commencing  the  operation  the  same  precau- 
tions should  be  taken  as  for  turning  :  the  woman  should  be  situated 
in  the  same  manner ;  however,  there  may  be  circumstances  in  which 
the  accoucheur  need  not  alter  her  position  ;  fof  example,  in  case  of 
convulsions,  hemorrhage,  or  extreme  debility,  indeed  any  circum- 
stances which  would  render  any  shock  or  movement  dangerous^, 
but  then  the  head  must  have  cleared  the  abdominal  strait,  in  which 
case  a  short  forceps  may  be  made  use  of,  such  as  Smellie'e,  for 
example. 

The  posture  on  the  side  adopted  by  the  English  for  spontaneous 
delivery  is  also  preferred  by  them  as  most  favourable  for  Ihe  appli- 
cations of  the  forceps,  which  I  can  hardly  conceive  of 

As  it  ia  wrong  to  introduce  the  forcqis  into  a  woman's  organs, 
without  adverlisihg  her  of  it,  I  think  the  best  mode  of  quieting  and 
jreassuring  her  ii^  to  show  her  the  mechanism  of  the  instrument. 


OCCIPITO-ANTERIOR  POSITION.  467 

There  should  be  in  readiness  some  warm  water  to  attemper  the 
instrument ;  and  some  butter,  oil,  or  mucilage,  to  make  it  slip  more 
easily  over  the  surfaces;  when  every  thing  is  properly  disposed  of,  and 
the  position  of  the  head  has  been  ascertained,  nothing  remains  but  to 
introduce  the  blades  ;  but  as  there  is  some  difference  in  the  maneu- 
vre,  according  as  the  occiput  is  directed  in  this  or  that  manner,  as 
the  head  descends  before  or  after  the  trunk,  I  shall  now  proceed  to 
examine  these  different  cases. 

§.  1.  Occipito-anterior  position. 

1066.  This  position,  the  most  advantageous,  and  most  frequent 
of  all,  requires  that  the  left  branch  should  be  introduced  first.  Two 
or  three  fingers  of  the  right  hand,  in  a  flattened  position,  are  to  be 
passed  up  betwixt  the  left  side  of  the  vagina  and  the  parietal  pro- 
tuberance, so  that  their  extremities  may  touch  the  os  uteri ;  the 
instrument  is  then  taken  by  the  left  hand,  as  a  writing  pen  is  held, 
and  the  handle  is  first  raised  high  up  in  front  of  the  woman's  right 
groin,  so  as  to  bring  the  other  extremity  in  the  line  of  the  axis  of 
the  vulva  or  inferior  strait :  as  for  the  introduction  of  the  hand,  the 
interval  between  two  pains  must  be  chosen  ;  it  is  introduced  gently, 
without  force ;  in  proportion  as  it  enters,  the  handle  is  by  degrees 
brought  from  above  downwards  and  from  right  to  left,  towards  the 
median  line  ;  after  this  it  is  frequently  necessary  to  place  the  thumb 
above  and  to  the  right  of  the  pivot,  instead  of  leaving  it  beneath  it;  it 
is  thus  moved  onwards,  making  it  follow  the  left  posterior  inclined 
plane  or  front  of  the  sacro-iliac  symphisis,  rather  than  the  left  side 
of  the  pelvis  properly  so  called,  until  its  entablement  shall  have  ar- 
rived between  the  labia  ;  after  which  the  handle  is  brought  near  the 
internal  surface  of  the  left  thigh,  depressing  it  more  or  less  accord- 
ing to  the  depth  to  which  the  blade  has  been  carried. 

During  this  introduction  the  point  of  the  clam,  held  very  strictly 
betwixt  the  head  of  the  fcstus  and  the  parts  of  the  woman,  ought 
never  to  deviate  from  the  curve  of  the  excavation.  By  deviating 
from  the  axes  of  that  cavity,  it  would  be  arrested  by  the  vagina, 
which  it  turns  up  in  folds,  or  might  lacerate  ;  if  inclined  too  much  in 
front  or  to  the  rear,  it  would  involve  the  bladder  oi-  rectum  in  the 
danger  of  being  wounded.  On  the  other  hand,  by  turning  too 
much  inwards,  which  almost  always  happens  in  using  a  forceps  with 
a  very  concave  blade,  it  abuts  against  the  child's  head,  and  is  soon 
stopped  by  the  folding  up  of  the  scalp  ;  so  that  in  any  way  it  would 
be  dangerous  to  introduce  it  by  force. 

Whenever,  therefore,  any  resistance  is  experienced  that  does  not 
appear  to  be  natural,  instead  of  pushing  it  on  with  too  much  vio- 


468  USE  OF  THE  FORCEPS, 

lence  the  instrument  should  be  withdrawn  a  little  ways  so  as  to  dis- 
engage it,  and  afterwards  slip  it  up  in  a  more  favourable  direction. 

Where  the  head  has  passed  through  the  os  uteri,  as  long  as  the 
forceps  does  not  abandon  the  fingers  that  are  in  the  vagina,  one 
must  be  very  awkward  to  go  amiss  ;  but  this  is  not  the  case 
where  the  head  is  almost  inaccessible,  and  where  the  circle  of  the 
■orifice  still  envelops  it  in  the  shape  of  a  crown  fitting  more  or  less 
tightly.  The  greatest  attention  is  necessary  here  :  if  the  end  of  the 
clam  deviates  from  the  cranium,  it  slides  over  the  outer  surface  of 
the  OS  uteri,  and  gets  into  the  cul  de  sac,  or  circular  groove  formed 
by  the  vagina,  where  it  is  attached  to  the  neck  of  the  uterus.  If 
the  accoucheur  should  not  perceive  this  deviation,  it  is  easy,  without 
pointing  them  out,  to  comprehend  the  havoc  and  danger  that  might 
ensue.  However,  in  order  to  avoid  them,  it  suffices  never  to  make 
the  instrument  penetrate  beyond  the  parietal  protuberances  without 
being  previously  assured  of  the  position  and  state  of  the  os  uteri. 

1067.  When  we  are  sure  that  the  left  branch  is  well  placed,  an 
assistant  takes  hold  of  it  and  keeps  it  in  contact  with  the  thigh 
while  the  physician  introduces  the  other. 

This  one  is  to  be  taken  in  the  right  hand,  and  guided  by  the 
fingers  of  the  left,  to  the  right  side  of  the  pelvis,  or  corresponding 
sacro-iliac  symphisis  ;  to  make  it  enter,  we  are  to  act  exactly  as 
was  just  now  directed,  in  speaking  of  the  left  branch.  If  the  occi- 
put is  inclined  to  the  left,  we  endeavour  to  move  the  blade  forwards 
behind  the  right  thyroid  foramen.  If  it  be  a  right  occipito-acetabu- 
lar  position,  on  the  contrary,  we  leave  it  in  front  of  the  sacro-iliac 
symphysis,  while  we  endeavour  to  get  the  left  branch  behind  the  left 
acetabulum. 

1068.  In  order  to  be  able  to  unite  the  two  branches  of  the  for- 
ceps, they  must  both  be  at  the  same  depth  in  the  pelvis ;  the  mortise 
in  one  must  correspond  exactly  to  the  pivot  in  the  other ;  their  place 
of  crossing  must  not  be  more  to  the  right  than  to  the  left,  and  their 
handles  must  be  sufficiently  depressed.  When  the  occiput  ia  behind 
the  symphysis  pubis,  it  is  sometimes  difficult  to  fix  them  exactly 
upon  the  sides  of  the  pelvis;  they  incline  towards  each  other  at  their 
convex  edges,  while  their  concave  edges  tend  to  separate,  which 
doubtless  depends  upon  the  head  being  not  so  thick  towards  the 
forehead  as  towards  the  occiput.  This  difficulty  may  be  overcome 
by  taking  a  firm  hold  of  the  blunt  hooks  of  the  forceps,  so  as  to  use 
thera  as  a  bent  lever  of  the  third  kind,  but  we  should  be  very  sure 
that  the  obstacle  depends  upon  no  other  cause.  By  following  this 
precept,  the  concavity  of  the  blades  comes  to  be  applied  over  the 
parietal  protuberances  when  the  occipito-frontal  diameter  is  in  line 


OCCIPITO-ANTERIOR  POSITION.  469 

with  the  sacro-pubic,  and,  in  the  oblique  positions,  the  vertex  is  dis- 
placed,  and  promptly  directs  itself  to  the  top  of  the  arch  of  the  pubis. 
Further,  it  is  evident  that  when  the  head  is  too  firmly  fixed,  one 
of  the  branches  of  the  forceps  will,  under  efforts  of  this  kind,  resist 
less  than  the  other,  and  place  itself  under  the  corresponding  anterior 
inclined  plane  of  the  pelvis ;  so  that  the  three  occipito-anterior  po- 
sitions, so  far,  do  not  sensibly  differ  from  each  other  as  regards  the 
application  of  the  instrument.  The  hand  generally  suffices  to  turn 
the  pivot,  otherwise  the  kind  of  lever  called  the  key  of  the  forceps 
is  had  recourse  to. 

1069.  In  the  next  place,  we  ascertain  that  the  head  is  the  only 
part  embraced  by  the  blades,  and  that  the  os  uteri,  the  womb,  or  some 
other  part  of  the  woman  is  not  taken  hold  of;  the  mode  of  acquiring 
a  degree  of  certainty  upon  this  point,  consists  in  moving  the  instru- 
ment gently  from  handle  to  handle^  in  the  direction  of  the  axes  of 
the  pelvis.  If  it  moves  readily,  and  without  making  the  woman 
suppose  that  she  is  getting  torn  or  pinched^  there  is  nothing  to  fear ; 
in  the  contrary  case,  it  is  almost  certain  that  some  fold  of  the  genital 
organs  has  got  pinched  in  the  clams  of  the  instrument,  and  until  the 
head  shall  have  been  more  properly  embraced,  all  pulling  and  every 
species  of  pressure  should  be  carefully  avoided. 

1070.  In  operating  with  a  view  to  lessen  the  size  of  the  head,  a 
loop  of  ribbon,  of  thread,  or  of  a  fillet,  is  fixed  on  one  of  the  blunt  hooks 
of  the  forceps ;  a  turn  is  then  made  over  the  other  branch,  and  the 
handles  are  brought  as  near  together  as  is  deemed  necessary  ;  the 
fillet  is  then  carried  over  the  first  handle,  then  brought  back  over 
the  second,  and  so  in  the  form  of  a  figure  8  until  it  is  all  used  ;  it 
being  well  understood  that  the  pressure  exerted  must  be  greater  or 
less,  according  to  the  degree  of  reduction  which  it  is  desirable  to 
obtain. 

1071.  Where  the  passage  is  capacious  and  the  forceps  is  only 
had  recourse  to  for  the  purpose  of  speedily  delivering  the  woman, 
this  compressing  method  may  indeed  be  dispensed  with  ;  neverthe- 
less, as  it  is  always  well  to  have  both  hands  disposable,  so  as  to  be 
able  to  rest  them  from  time  to  time,  it  seems  to  me  better  to  apply 
the  fillet  as  recommended,  in  all  cases,  with  this  difference,  that 
under  the  circumstances  now  supposed,  it  is  employed  solely  for  the 
purpose  of  keeping  the  branches  of  the  forceps  in  a  fixed  and  pro- 
perly approximated  situation. 

Afler  having  wrapped  the  handles  in  a  napkin,  the  right  hand  is 
placed  near  the  blunt  hooks,  above  as  long  as  it  is  necessary  to  pull 
in  the  axis  of  the  superior  strait,  and  below,  on  the  contrary,  when 
the  head  is  at  the  inferior  strait ;  the  leil  hand  is  applied  at  the  roots 


470  USE  OF  THE  FORCEPS. 

of  the  blades,  beyond  the  pivot,  below  when  the  right  hand  is  above, 
and  above  when  it  is  underneath. 

1072.  The  forceps  being  properly  held,  and  the  head  firmly 
grasped,  before  we  begin  to  pull  downwards  the  occiput  must  be 
directed  diagonally,  provided  it  be  still  at  the  superior  strait ;  if  it 
be  in  the  excavation,  it  is  brought  behind  the  symphysis  pubis.  To 
compel  it  to  descend  to  the  centre  of  the  pelvis,  and  to  prevent  the 
forehead  from  descending  prematurely,  it  has  been  recommended  to 
sustain  the  latter  with  a  couple  of  fingers  of  the  left  hand  ;  but  I 
think  it  would  be  wrong  to  place  much  dependence  upon  this  pre- 
caution, which,  besides,  deprives  the  accoucheur  of  a  great  portion 
of  his  power.  I  prefer  trusting  to  the  depression  of  the  handles,  to 
such  an  extent  as  to  keep  the  blades  in  the  axis  of  the  superior  strait, 
and  to  tractions  performed  in  the  same  line  of  direction, 

1073.  If  the  head  is  locked,  or  too  firmly  fixed  at  the  superior 
strait,  we  first  attempt  to  start  it  as  we  start  a  cork  in  a  bottle  or  a 
nail  that  we  want  to  draw;  it  is  then  to  be  pushed  up  so  as  to  oblige 
the  occiput  to  descend  in  a  more  favourable  manner.  We  are  to 
pull  obliquely  downwards  and  backwards  until  the  strait  is  com- 
pletely cleared  ;  as  soon  as  the  rotation  movement  is  effected,  and 
the  head  is  in  a  direct  antero-posterior  position,  we  ought,  in  puUing, 
to  move  the  handles  of  the  forceps  alternately  right  and  left,  until 
the  parietal  protuberances  have  passed  the  ischiatic  strait.  These 
tractions  ought  to  be  at  once  powerful,  slow,  and  moderate  ;  should 
there  be  no  reason  for  haste,  we  need  not  pull  except  during  the 
uterine  contractions,  which,  besides,  rarely  fail  to  become  very  ener- 
getic and  frequent  as  soon  as  we  commence  the  operation ;  but 
when  the  very  moments  are  counted,  or  the  womb  in  a  state  of  in- 
ertia, it  would  be  useless  or  dangerous  to  wait ;  we  ought  to  act 
immediately. 

1074.  When  the  head  reaches  the  vulva  and  is  retained  only  by 
the  soft  parts,  we  leave  off*  pulling  from  handle  to  handle.  We 
ought  even  not  to  pull  at  all,  provided  the  womb  appears  to  have 
preserved  a  sufliicient  degree  of  energy  to  enable  it  to  terminate  the 
labour ;  for  at  this  juncture  it  is  highly  important  not  to  proceed  too 
rapidly,  and  to  be  assured  that  the  best  way  of  managing  the  peri- 
neum is  to  retain  the  head  as  long  as  may  be  at  the  vulva.  In- 
stead, then,  of  engaging  the  woman  to  bear  down,  and  pulling  at 
the  same  time  with  great  force,  as  we  had  previously  done,  she  is 
urged  to  be  careful  of  making  strong  efforts  ;  it  is  often  best,  even 
to  withdraw  the  instrument,  which,  if  the  head  be  born,  requires  no 
particular  precaution,  while,  in  the  contrary  case,  the  blades  are  re- 
moved one  after  the  other,  holding  them  in  the  same  way  as  when 


OCCIPITO-POSTERIOR  POSITION.  47 1 

they  were  introduced,  and  beginning  with  the  right  branch,  which  is 
uppermost.  Should  it  be  afterwards  necessary  to  exert  any  tractive 
force,  it  might  be  effected  by  placing  the  fingers  upon  the  temples 
or  under  the  arm-pits  of  the  fcetus,  as  is  done  in  some  cases  of 
spontaneous  delivery. 

1075.  Authors  have  expressly  advised  that  the  noise  made  by  the 
striking  or  rubbing  of  the  two  branches  of  the  instrument  together 
should  be  avoided,  because,  say  they,  this  noise  might  frighten  the 
woman.  It  would  doubtless  be  imprudent  to  take  no  precaution  on 
this  head,  and  to  clash  the  blades  together  as  we  would  the  foils  at  a 
fencing  match  ;  but  I  can  perceive  no  reason  for  the  minute  precau- 
tions that  are  indicated  in  relation  to  the  matter  in  the  latest  publi- 
cations on  midwifery. 

§.  II.  Occipito-posterior  position. 

1076.  The  forceps  ought  to  be  introduced  and  fixed  in  the  same 
manner  as  in  the  former  position  ;  only,  it  is  unnecessary  to  depress 
the  handles  so  much  while  drawing  down  :  as  the  occiput,  which 
however  ought  to  emerge  first,  constantly  tends  to  lodge  against 
the  anterior  face  of  the  sacrum  and  coccyx,  which  is  very  long  and 
very  concave,  more  numerous  difiiculties  must  be  expected,  as  well 
as  greater  dangers  to  the  perineum.  But  the  operation  would  be 
still  more  dangerous  and  difficult,  if,  as  has  by  some  been  advised, 
the  concave  edge  of  the  instrument  should  be  turned  backwards  in- 
stead of  looking  towards  the  pubis.  In  the  first  place,  to  conform 
to  this  precept,  it  would  be  necessary  to  change  the  posture  of  the 
woman  ;  and  then  it  would  be  impossible  to  grasp  the  head  at  the 
superior  strait,  otherwise  than  in  a  line  from  the  anterior  fontanel  to 
the  nucha  ;  in  the  third  place,  as  the  forceps  would  no  longer  be 
parallel  with  the  curve  of  the  pelvis,  its  concave  edge  would,  during 
the  tractions,  of  necessity  press  the  vagina  and  bladder  with  violence 
against  the  pubis,  while  the  ends  of  the  blades  would  operate  in 
the  same  manner,  and  still  more  certainly  upon  the  soft  parts  be- 
hind. If,  on  the  other  hand,  the  head  should  be  grasped  only  with 
the  view  of  turning  the  occiput  round  to  the  front  of  the  pelvis,  as 
it  would  be  nearly  impossible  to  act  at  the  same  time  upon  the  trunk 
of  the  fcetus,  we  should  succeed  only  in  wringing  the  child's  neck. 
In  this,  as  in  the  occipito-anterior  position,  the  forceps  ought  there- 
fore to  be  so  placed  that  its  concave  edge  may  look  forwards,  even 
though  it  may  be  turned  towards  the  child's  forehead,  and  not  to- 
wards the  occiput,  as  the  general  rule  would  require. 

§.  III.  Left  occipito-iliac  position. 

1077.  It  does  not  appear  to  me  that  such  a  position,  in  the  exca- 


472  USE  OF  THE  FORCEPS. 

vation,  is  admissible  ;  but  should  it  ever  be  met  with  at  the  superior 
strait,  and  require  the  application  of  the  forceps,  I  do  not  see  bow 
we  could  dispense  with  following  the  precept  of  the  German  accou- 
cheurs, unless  indeed  we  should  imitate  M.  Flamant,  and  proceed 
beforehand  to  take  hold  of  the  head  with  the  hand  and  place  it  in  a 
more  convenient  position  ;  a  proceeding  much  easier  to  recommend 
than  to  execute,  in  a  majority  of  cases.  The  sacro-vertebral  angle, 
the  coccyx  and  the  perineum  would  not  admit  of  the  instrument  being 
placed  transversely  ;  at  least,  it  would  be  absolutely  impossible  to 
extract  in  the  direction  of  the  axis  of  the  superior  strait. 

1078.  Admitting,  however,  that  the  case  may  occur,  this  is  the 
advice  given  by  the  authors  :  the  right  branch  of  the  forceps  is  to  be 
introduced  first,  and  conducted  with  the  ordinary  precautions,  in 
front  of  the  right  sacro-iliac  symphysis,  as  high  up  as  the  forehead  ; 
then  the  ends  of  the  first  fingers  of  the  left  hand  are  placed  under 
its  convex  edge,  and  in  concert  with  the  right  hand  move  it  from 
behind  forwards  and  from  right  to  left,  until  its  concave  edge  is 
turned  towards  the  left  iliac  fossa,  and  the  blade  has  arrived  upon 
the  right  parietal  protuberance.  The  handle,  strongly  depressed, 
is  then  given  to  an  assistant,  who  holds  it  against  the  woman's 
left  thigh. 

1079.  The  left  branch  is  held  in  tHe  left  hand,  and  passed  up 
along  the  posterior  part  of  the  pelvis  until  its  point  is  above  the 
superior  strait,  and  the  pivot  even  with  the  mortise  that  is  in  the  other 
branch.  After  having  joined  them  and  dislodged  the  head,  if  it  be 
still  in  the  superior  strait,  and  forced  the  occiput  to  descend  into 
the  excavation,  provided  it  were  not  already  there,  the  concave 
edges  of  the  instrument  are  gradually  brought  to  the  front,  and  the 
remainder  of  the  operation  is  conducted  as  in  the  occipito-pubic 
positions. 

§.  IV.  Right  occipito-iliac  position. 

What  I  have  just  now  said  of  the  left  occipito-iliac  position  is 
entirely  applicable  to  the  right  occipito-iliac  position ;  they  only 
differ  from  each  other  in  regard  to  the  application  of  the  forceps, 
in  doing  which  the  left  branch  is  to  be  introduced  first. 

§.  V.  Positions  of  the  pelvis. 

It  may  happen  that  after  the  child  has  been  drawn  down  by  its 
pelvic  extremity,  great  difficulty  shall  be  experienced  in  attempting 
to  disengage  the  head.  The  same  thing  may  be  met  witii  at  the 
close  of  a  pelvis  labour  which  up  to  that  moment  had  exhibited  no- 
thing peculiar ;  if  the  fingers  and  hands  do  not  suffice  for  the  deli- 


PELVIS  POSITIONS.  473 

very  of  the  woman,  it  will  probably  be  found  that  it  is  occasioned 
by  a  contraction  of  the  pelvis,  more  or  less  considerable,  in  which 
case  the  forceps  may  be  of  little  avail.  However,  it  must  be  tried, 
rather  than  resort  to  symphyseotomy  or  the  cesarian  operation, 
particularly  provided  the  head  is  below  the  superior  strait. 

If  the  occiput  is  in  front  or  a  little  to  one  side,  an  assistant  should 
raise  the  trunk  upwards,  and  first  the  left  branch,  then  the  right  is 
introduced,  following  the  same  rules  as  if  the  head  had  descend- 
ed first. 

If  it  is  behind,  and  it  be  found  impossible  to  turn  it  round  to  the 
front  of  the  pelvis  by  means  of  the  hands,  the  fcetus  is  to  be  turned 
back  over  the  perineum,  and  the  branches  of  the  forceps  are  still  to 
be  introduced  as  before.  But  in  extracting  the  head  we  should 
endeavour  to  act  with  sufficient  force  upon  the  forehead  and  chin 
to  make  those  parts  descend  early  under  the  symphyses  of  the  pubis. 

Lastly,  should  it  be  found  on  one  side,  the  trunk  ought  first  to  be 
moved  to  the  right  or  to  the  left,  and  then  we  should  proceed  as 
has  been  directed  for  the  corresponding  positions  of  the  vertex. 

Thus,  in  all  cases,  the  trunk  is  to  be  turned  towards  the  direction 
in  which  the  occiput  looks,  and  the  forceps  introduced  along  the 
sides  of  the  head,  in  such  a  way  that  the  concavity  of  its  edges  may 
be  towards  the  front,  or  shall  be  brought  there  in  the  progress  of 
the  operation. 

1080.  It  is  easy  to  perceive  that  the  presence  of  the  trunk  must 
add  to  the  difficulties  that  are  experienced  in  head  presentations. 
Still,  many  practitioners  have  thought,  that  under  such  circumstances 
the  fingers  might  be  beneficially  substituted  for  the  forceps,  and  that 
it  is  entirely  useless  to  attempt  its  application  where  the  head  has 
not  yet  reached  the  excavation. 

This  seems  to  me  to  be  dangerous  doctrine.  I  know  very  well 
that  a  skilful  accoucheur  will  generally  triumph  over  the  difficulties 
presented  by  this  position  without  having  recourse  to  the  forceps ; 
I  am  also  aware  that  the  forceps,  here,  cannot  easily  be  applied  to 
the  head  at  the  superior  strait ;  but  it  is  also  undeniable  that  the. 
head  may  be  arrested  at  the  superior  strait  by  such  a  degree  of  con- 
traction that  the  best  combined  eflbrts  of  the  hand  shall  be  insufficient 
for  its  extraction  ;  but,  why  should  not  the  forceps  ofl^er  the  same 
advantages  in  this  case  as  in  the  positions  of  the  vertex  ?  Moreover, 
■excepting  symphyseotomy,  what  other  means  is  there  of  extracting 
I  the  foetus  alive  ?  I  will  add,  that,  the  trunk  being  without,  and  the 
head  in  some  measure  beyond  the  reach  of  the  uterine  contractions, 
any  force  exerted  upon  the  body  with  the  hand,  and  sufficient  to 
enforce  its  passage  through  the  organs,  will  generally  act  on  the 
3K 


474  USE  OF  THE  FORCEPS. 

spine  of  the  child  to  the  extent  of  seriously  compromitting  its  exist- 
ence, whereas  the  forceps  does  not  exporjj  it  to  the  same  dangers. 

1081.  Consequently  we  may  have  recourse  to  the  forceps,  in 
pelvis  presentations,  1 .  When  the  head  is  stopped  by  the  inferior 
strait  only,  and  we  are  convinced  that  the  powers  of  the  hand 
alone  would  be  insufficient,  or  too  dangerous  ;  2.  When  the  same 
part  has  not  cleared  the  superior  strait.  But  then,  it  must  be  en- 
gaged in  it,  or  at  least  the  face  must  be  chiefly  in  the  excavation, 
and  it  must  be  possible  to  reach  the  os  uteri  with  some  of  the 
fingers.  It  is  well  understood,  moreover,  that  in  both  cases,  the 
chin  must  have  been  previously  forced  to  descend,  the  head  must 
have  executed  its  rotation  movement,  and  the  shoulders  must  have 
been  disengaged. 

§.  VI,  The  child  is  completely  or  partially  double.  .^ 

1082.  In  cases  where  two  children  are  united  to  each  other  at 
their  anterior  or  posterior  surface,  and  where  two  large  heads  are 
supported  by  a  single  trunk,  it  is  possible  that  the  efforts  both  of  the 
woman  and  accoucheur,  although  properly  combined,  may  be  insuf- 
ficient to  efiect  the  delivery  without  the  aid  of  the  forceps. 

If  the  trunk  or  the  two  trunks  have  escaped,  it  will  be  necessary, 
in  order  to  admit  of  the  application  of  the  instrument,  that  one  of 
the  head's  shall  be  in  the  excavation  ;  nor,  provided  the  monstrous 
fcEtus  should  present  by  the  vertex,  ought  this  instrument  to  be  re- 
jected, although  neither  of  the  two  heads  should  have  cleared  the 
superior  strait.  In  the  former  case,  that  is  to  say,  where  the  trunk 
is  delivered,  the  head  nearest  the  posterior  plane  of  the  pelvis  ought 
to  come  down  first,  and  in  the  latter,  on  the  contrary,  that  one  which 
is  naturally  turned  towards  the  pubes. 

Finally,  the  operation,  if  conducted  agreeably  to  the  general  rules 
indicated  higher  up,  would  require  no  other  precaution  than  that  of 
raising  the  handle  of  the  forceps  forcibly  upwards  at  an  early 
period,"  and  to  pull,  ahmost  from  the  commencement,  in  the  line  of 
the  axis  of  the  vulva.  This  would  be  the  only  way  to  avoid  forcing 
the  second  head,  still  contained  in  the  womb,  to  reverse  itself,  or  to 
remain  hitched,  as  it  were,  above  the  pubis  or  the  sacro  vertebral 
angle. 

§.  VII.  The  head,  separated  from  the  body,  remains  alone  in  tht. 
pelvis.  ' 

1083.  Formerly  so  little  care  was  taken  in  regard  to  the  extrac- 
tive force  exerted  upon  the  foetus,  when  it  was  deemed  necessary  to 
deliver  it  footling,  (hat  it  was  not  very  uncommon  to  see  the  neek  part 


DETRUNCATED  HEAD  IN  PELVIS.  475 

from  the  head,  and  the  trunk  thus  torn  off  during  the  violence  of 
the  exertions.  At  the  present  day  this  accident  could  happen  only 
to  the  most  ignorant  or  thoughtless  practitioner  ;  for  it  is  never 
allowable  to  employ  a  force  with  the  hand  alone^  sufficient  to  pro- 
duce the  occurrence.  It  is  only  where  one  of  the  passages,  of  size 
sufficient  to  admit  of  the  transit  of  the  trunk,  is  so  contracted  as 
completely  to.arrestthe  head,  that  it  might  perhaps  become  useful  to 
separate  the  portion  of  the  child  that  is  without  from  that  which 
remains  enclosed  within  the  genital  organs. 

But  admitting  that  this  necessity  does  exist  in  some  cases,  it  still 
must  be  very  rare,  since  the  delivery  of  the  body  does  not  absolute- 
ly prevent  the  application  of  the  forceps  to  the  head  ;  nevertheless, 
as  we  unfortunately  meet  with  a  good  many  persons  who  undertake 
the  practice  of  midwifery  without  possessing  the  least  knowledge 
of  the  subject,  it  would  be  imprudent  for  the  educated  practioner 
not  to  reflect  upon  what  he  would  do  if  called  to  a  woman  whose 
foetus  had  been  thus  detruncated,  either  voluntarily  or  involuntarily, 
by  immoderate  pulling  or  by  means  of  an  instrument. 

1084.  In  the  first  place,  the  head  must  be  placed  in  a  proper 
situation,  that  is  to  say,  its  occipito-mental  diameter  must  be  adapt- 
ed to  the  axes  of  the  pelvis,  and  the  face  turned  backwards. 

When  in  the  excavation,  it  is  almost  as  easy  to  get  hold  of  it  as 
if  it  were  not  separated  from  the  body.  At  the  sup^ior  strait,  the 
operation  is  often  found  to  be  one  of  the  utmost  difficulty,  and  appears 
to  be  even  impracticable,  when  the  womb  is  scarcely  contracted, 
and  the  face  and  occiput  are  not  yet  engaged.  When  the  head  is 
firmly  fixed  by  the  contraction  of  the  uterus,  or  when  it  can  be  kept 
still  with  the  hand,  so  as  not  to  slip  out  of  the  grasp  of  the  instru- 
ment, we  are  to  proceed  just  as  if  the  body  were  still  attached  ;  only, 
in  order  to  make  surer  of  its  not  turning  so  as  to  put  the  occipito- 
frontal in  place  of  the  occipito-mental  diameter  during  the  process 
of  extraction,  we  should  endeavour  to  steady  it  by  applying  a  couple 
of  fingers  of  the  hand  that  holds  the  root  of  the  forceps  near  the 
vulva,  to  the  face  or  chin. 

§.  VIII.  Recapitulation,  on  the  employment  of  the  forceps. 
In  bringing  this  article  to  a  close,  I  think  it  a  duty  to  repeat  the 
following  corollaries  : 

1.  The  forceps  ought  never  to  be  applied  without  an  evident 
necessity,  because,  although  it  migiit  not  be  mischievous  to  the 
child,  the  mother  may  receive  the  greatest  injury  from  it. 

2.  In  the  practice  of  good  accoucheur^  the  forceps  is  scarcely 
employed  once  in  two  hundred  labours ;  and  as  every  thing  tends  to 


476  USE  OF  THE  FORCEPS. 

show  that  the  ergot  will  be  advantageously  substituted  for  it  in  a  mul- 
titude of  cases,  its  employment  will  doubtless  continue  to  be  more 
and  more  rare.  Most  of  those  who  make  a  more  frequent  use  of 
it  are  not  wrong  merely  because  they  perform  an  operation  that  is 
useless,  bat  also,  and  especially,  because  they  needlessly  derange  the 
progress  of  a  natural  function  ;  and  because  they  voluntarily  expose 
themselves  to  the  risk  of  complicating  the  sequel  of  delivery,  even 
admitting  they  are  sure  of  not  wounding  any  organ. 

3.  The  forceps  cannot  be  beneficially  applied,  except  to  the  head, 
either  when  it  descends  foremost,  or  when  it  follows  the  trunk  of 
the  body. 

4.  It  is  much  more  to  be  relied  on  for  the  purpose  of  grasping, 
and  extracting  the  head,  than  for  diminishing  its  size. 

5.  It  is  not  allowable  to  introduce  it  into  the  womb  until  the  ori- 
fice is  sufliciently  dilated,  and  the  head  ceases  to  be  movable  and 
loose  above  the  superior  strait. 

6.  As  far  as  possible,  the  blades  of  the  forceps  ought  accurately 
to  embrace  the  two  sides  of  the  head  in  the  direction  of  the  occipito- 
mental diameter ;  nevertheless,  where  some  difliculty  or  doubt  is 
experienced,  it  is  more  convenient  and  more  prudent  to  pass  them 
up  along  the  sides  of  the  pelvis. 

7.  Except  in  the  right  occipito-iliac  position,  if  it  ever  does  occur, 
and  we  should  wish  not  to  grasp  the  head  by  the  occiput  and  fore- 
head, the  left  branch  must  always  be  introduced  first,  because  it  is 
the  undermost. 

8.  In  whatever  manner  the  branches  are  introduced,  their  concave 
edges  must  be  ultimately  brought  in  front ;  but  if  the  head  had  been 
seized  by  the  ends  of  its  occipito-frontal  diameter,  and  had  not,  while 
<lescending,  rotated  between  the  clams  of  the  instrument,  it  must  be 
abandoned  at  the  inferior  strait,  to  be  taken  hold  of  more  advantage- 
ously, should  the  forceps  still  continue  to  be  necessary. 

9.  The  extraction  should  always  be  performed  in  the  line  of  the 
axes  ;  always  with  gentleness,-never  precipitately, nor  by  jerks;  the 
tractions  from  handle  to  handle  are  of  no  use  after  the  head  occupies 
the  vulva,  and  if  performed  while  it  is  at  the  superior  strait,  would 
sometimes  be  dangerous. 

10.  It  is  not  only  because  it  has  become  useless  that  the  instru- 
ment should  be  taken  ofl'  when  the  head,  at  the  lower  strait,  is  only 
resisted  by  tiie  soft  parts,  but  also,  and  chiefly,  in  the  view  of  avoiding 
laceration  of  the  perineum,  and  allowing  the  vulva  to  dilate  more 
slowly  and  regularly. 


THE  LEVER.  477 


ARTJCLE  III. 
Of  the  Lever. 

SECTION  1. 
Of  the  Lever  in  itself  considered. 

1085.  Herbiniaux,  and  Denman,  the  British  Baudelocque,  have 
decidedly  maintained  that  the  lever  is  incomparably  superior  to  the 
forceps ;  and  notwithstanding  that  it  has  not  been  so  highly  thought 
of  in  France,  it  has  occupied  much  of  the  attentios  of  the  physicians 
of  our  country  since  the  middle  of  the  last  century. 

1086.  Its  inventor  is  no  better  known  than  that  of  the  forceps. 
Was  the  idea  of  it  derived  from  the  uncus  of  Celsus  or  the  curette 
of  the  lithotomists  ?  Is  it  the  instrument  made  use  of  by  the  Cham- 
berlains, as  Mulder  pretends,  or  the  spoon  of  Palfyn,  or  one  of 
the  branches  of  Smellie's  forceps,  variously  modified  ?  Still  it  is 
true  that  Roonhuysen,  who  made  a  secret  of  it,  acquired  celebrity 
as  an  accoucheur,  by  means  of  a  peculiar  instrument,  since  used 
under  the  title  of  Roonhuysen' s  lever.  This  instrument,  which, 
from  Roonhuysen  passed  into  the  hands  of  Bruyn,  was  purchased 
and  made  public  by  de  Vischer  and  Van  de  Poll  in  1753;  but,  as 
was  the  case  with  regard  to  the  forceps,  a  great  number  of  very 
discrepant  accounts  of  it  appeared  in  the  course  of  a  short  time ; 
there  was  soon  a  lever  by  Boom,  another  of  De  Bruyn,  a  third  by 
Titsing,  one  by  Palfyn  or  Heister,  one  by  Cole,  one  by  Griffith,  a 
lever  by  Wathen,  one  by  Aitken,  &c.  There  was  no  less  discre- 
pancy upon  its  mode  of  acting :  according  to  some  it  was  to  be  ap- 
plied to  the  occiput,  potentia  agit  in  as  occipitis,  was  the  family 
secret ;  according  to  others  it  was  to  be  applied  to  the  temples ; 
Titsing  directed  it  to  be  applied  to  the  mastoid  process  ;  and  lastly, 
others  thought  it  should  be  fixed  upon  the  side  of  the  chin.  As  to 
its  advantages,  if  De  Bruyn  was  to  be  bdieved,  they  were  immense, 
no  difficulty  could  withstand  it ;  whether  the  head  were  reversed, 
arrested  or  locked,  the  lever  triumphed  over  them  all,  and  by  means 
of  this  marvellous  instrument,  the  Dutch  accoucheur  pretends  to 
have  unlocked  eight  hundred  heads  in  the  course  of  forty-two  years. 
The  French  authors  have,  on  the  contrary,  maintained  that  it  is 


I 
I 


478  THE  LEVER. 

\ 
onl3^  useful  in  correcting  the  positions  of  the  head,  in  compelling  the 
reverted  occiput  to  replace  itself  at  the  centre  of  the  pelvis. 

1087.  However  this  may  be,  instead  of  a  bar  of  steel  about  ten 
inches  long  by  an  inch  and  a  half  in  breadth,  curved  at  each  end  hke 
a  spatula,  enveloped  in  adhesive  plaster,  according  to  De  Bruyn,  or 
charaoy  leather,  as  Boom  says  ;  instead  of  a  simple  spatula  or  kind 
of  flat  spoon,  the  handle  of  which  was  terminated  by  a  broad  ring, 
which  constituted  the  lever  of  Titsing,  the  modern  lever,  such  as  it 
appeared  when  modified  by  iPean  and  Baudelocque,  is  nothing  more 
than  one  of  the  branches  of  Smellie's  forceps,  very  much  elongated, 
without  its  notch,  and  very  little  curved.  This  stock,  the  blade 
of  which  is  very  widely  fenestrated,  and  the  root  supported  by  an 
ebony  handle,  has  also  been  itself  modified  in  a  great  variety  of 
ways  by  the  moderns,  either  in  regard  to  its  length,  or  the  degree 
and  shape  of  its  curve,  or  because  some  have  added  a  joint  in  the 
stock,  so  as  to  bend  and  make  it  more  portable. 

SECTION  2. 
Use  of  the  Lever. 

1088.  Subsequently  to  the  idea  originated  by  the  axiom  of  Roon- 
huysen,  and  which  has  particularly  been  adopted  among  us,  it  was 
generally  agreed  that  the  lever  is  not  destined  to  supply  the  place 
of  the  forceps,  that  at  most  it  can  but  serve  to  restore  the  flexion- 
movement  of  the  head,  by  hooking  down  the  occiput ;  thenceforth 
its  employment  necessarily  became  much  restricted,  for  under  those 
circumstances  the  fingers  almost  always  suflice,  and  if,  after  all,  any 
instrument  were  necessary,  one  of  the  branches  "of  the  forceps 
would  answer  as  good  a  purpose  as  the  lever  itself. 

But  this  is  not  the  view  the  English  accoucheurs  take  of  the  sub- 
ject, nor  that  taken  by  its  inventors,  nor  indeed  is  it  a  correct  one. 

1089.  The  lever  is  an  instrument  that  is  applicable  to  two  differ- 
ent objects  :  on  the  one  hand,  it  may  be  employed  for  the  purpose 
of  restoring  or  reducing  the  head  to  its  natural  position  ;  and  on  the 
other,  it  is  possible  to  make  use  of  it,  as  we  do  of  the  forceps,  to 
extract  the  head  when  it  has  descended  into  the  excavation.  In  the 
former  case,  the  fingers,  or  one  branch  of  the  forceps,  might,  strictly 
speaking,  in  most  circumstances,  be  substituted  for  it :  but,  in  the 
latter,  I  am  convinced  that  it  is  susceptible  of  advantageously 
taking  place  of  the  forceps,  and  that  pretty  frequently.  In  the  first 
case  it  acta  upon  the  occiput,  or  on  a  parietal  protuberance  like  a 


USE  OF  THE  LEVER.  479 

simple  crotchet ;  in  the  second,  it  really  performs  the  office  of  a 
lever  of  the  first  kind. 

As  a  crotchet,  the  lever  ofiered  for  sale  by  the  different  cutlers  in 
the  vicinity  of  the  Ecole  de  Medicine,  and  which  is  very  nearly  the 
instrument  modified  by  Pean  and  Baudelocque,  leaves  nothing  to  be 
desired  ;  as  a  lever,  T  prefer  one  that  is  rather  shorter,  and  that  may 
shut  up  by  means  of  a  hinge  joint,  which  does  not  at  all  diminish  its 
strength ;  further,  it  ought  to  be  strait  from  the  extremity  of  the 
handle  to  within  about  three  inches  of  the  end  of  the  blade  ;  the 
latter  should  be  broad,  oval,  and  ending  in  a  long  flat  root,  which 
narrows,  gradually,  to  continue  into  the  handle  ;  its  curve  should  be 
considerable,  at  least  greater  than  that  of  the  forceps  ;  with  the  ex- 
ception of  the  middle  part,  its  concavity,  that  which  ought  specially 
to  bear  upon  the  head,  it  ought  to  be  very  well  polished;  and  lastly, 
in  the  construction  of  such  instruments  the  best  steel  ought  to  be 
selected. 

§.  I.  Use  of  the  lever  as  a  crotchet. 

1090.  If  then  it  be  intended  to  make  use  of  the  lever  in  con- 
formity to  the  principles  of  the  French  authors,  it  must  be  taken 
hold  of  with  the  right  hand  for  the  right  occipito-iliac  position,  and 
with  the  left  hand  in  a  case  of  the  left  occipito-iliac  position,  and 
with  either  hand  in  the  antero-posterior  positions.  Introduced  with 
the  same  precautions  as  if  it  were  one  of  the  branches  of  the  for- 
ceps, it  is  passed  up  between  the  surface  of  the  genital  organs  and 
the  child's  head,  until  it  gets  beyond  the  occipital  projection  or  pari- 
etal protuberance,  and  in  such  a  way  that  its  concavity  may  be 
easily  applied  to  one  of  the  parts  above  mentioned  ;  as,  in  the  occi- 
pito  and  fronto-pubic  positions,  it  is  impossible  to  pass  it  up  directly 
behind  the  occiput,  it  must  be  at  first  carried  a  little  to  one  side, 
and  afterwards  conducted  on  the  part  which  it  is  intended  to  de- 
press ;  when  it  is  well  placed,  the  hand  that  directed  the  blade  takes 
hold  of  the  root  of  the  instrument ;  in  order  to  make  sure  that  it 
shall  not  slip,  and  that  the  back  of  it  shall  not  rub  against  the  soft 
parts  of  the  woman,  the  operator  should  employ  the  extracting  force 
with  the  hand  that  holds  the  handle,  in  a  direction  backwards,  for- 
wards, or  sideways  ;  in  short,  in  a  direction  opposite  to  that  pointed 
to  by  the  protuberance  which  he  wishes  to  depress.  In  general,  the 
intervals  between  the  pains  is  to  be  selected  for  acting,  and  as  soon 
as  the  vertex  has  x-eached  the  centre  of  the  pelvis,  the  operation  is 
complete  ;  the  instrument  is  to  be  withdrawn,  and  the  labour  aban- 
doned to  itself;  or,  if  necessary,  other  means  of  assisting  it  are  re- 
sorted to. 


I 


480  THE  LEVER. 

§.  II.  Of  the  Lever  used  as  a  Lever. 

1091.  The  use  of  the  lever  after  the  manner  of  the  Dutch  and 
English  accoucheurs,  that  is,  as  a  substitute  for  the  forceps,  is  very 
simple  as  to  its  mechanism :  in  the  first  place,  it  is  best  that  the  bead 
should  be  in  the  excavation  ;  then  that  it  should  have  already,  or  at 
least  chiefly  executed  its  pivot-movement ;  in  the  third  place,  that 
there  should  be  but  a  slight  degree  of  contraction  of  the  inferior 
strait,  or  that  the  retardation  of  the  labour  should  depend  solely 
upon  a  want  of  action  of  the  womb,  or  of  the  woman  herself. 
Whatever  may  be  the  position  of  the  head,  the  right  hand  must  be 
made  use  of  for  extracting  with,  at  least  in  all  cases  where  the  ac- 
coucheur is  not  left-handed  ;  for  the  purpose  of  introducing  it,  we 
have  recourse  to  the  right  hand,  if  the  lever  is  to  be  passed  upon 
the  right  side  of  the  pelvis,  and  to  the  left  hand  in  the  contrary 
case. 

1092.  Where  the  occiput  is  in  front  or  somewhat  to  the  left,  the 
left  hand  introduces  the  lever,  as  if  it  were  the  right  branch  of  the  for- 
ceps, in  front  of  the  right  sacro-iliac  symphysis  ;  when  it  has  passed 
up  sufficiently  far,  the  action  of  the  two  hands  is  combined  so  as  to 
guide  the  concavity  of  its  blade  on  to  the  right  temporo-parietal  re- 
gion, that  is  to  say,  in  the  direction  of  the  occipito-mental  diameter, 
and  on  to  the  same  parts  that  would  be  embraced  by  the  corres- 
ponding blade  of  the  forceps.  The  left  side  of  the  vertex  is  sup- 
ported by  the  fingers  of  the  left  hand  ;  the  thumb,  placed  near  to 
the  vulva,  embraces  the  back  of  the  lever,  to  which,  conjointly  with 
the  right  side  of  the  pubic  arch,  it  serves  as  a  -point  d'appui ;  we 
are  now  to  wait  for  a  pain,  and  then  draw  down  slowly  but  strong- 
ly, as  if  we  were  making  a  lever  of  the  first  kind  swing  from  below 

■i^'-^ upwards,  and  from  left  to  right;  the  head  generally  yields  readily  ; 
it  is  gradually  drawn  down  in  the  axis  of  the  inferior  strait,  which  it 
clears  as  it  executes  its  extension-movement. 

In  this  way  the  force  exerted  upon  the  head  acts  in  a  direction 
from  the  chin  towards  the  occiput,  or  in  that  of  a  line  drawn  from 
the  angle  of  the  right  jaw  to  llie  left  side  of  the  vertex ;  so  that, 
as  it  is  supported  elsewhere  by  the  left  side  of  the  pelvis,  there  is 
nothing  surprising  in  the  circumstance  that  it  allows  itself  to  be  so 
easily  extracted. 

1093.  Should  the  occiput  be  on  the  right  side,  in  the  second  posi- 
tion for  example,  the  lever  ought  to  be  introduced  with  the  left 
hand  ;  but  then  it  must  be  changed,  as  above,  and  the  right  hand 
seizing  the  handle  of  the  instrument,  should  also  extract  in  the  same 
mann«ir,  with  this  difference  only,  that  the  see-saw  movement  should 
take  place  from  right  to  left,  and  not  from  left  to  right. 


THE  LEVER.  481 

Should  the  vertex  be  turned  backwards  instead  of  towards  the 
front  of  the  pelvis,  the  lever  ought  to  be  applied  to  the  temporo- 
parietal region,  in  the  direction  of  the  occipito-bregnKitic  diameter, 
and  the  sce-saw  should  be  performed  in  such  a  way  that  the  occiput 
which  ouglit  here  to  support  the  principal  effort,  may  escape  first,  in 
front  of  the  perineum,  and  be  strongly  raised  towards  the  centre 
of  the  vulva  ;  this  position  is  less  favourable  than  the  other,  without 
doubt,  but  still,  it  is  not  very  difficult. 

1094.  I  know  that  what  the  lever  effects  under  these  circum- 
stances could  be  equally  well  done  by  the  forceps,  and  perhaps 
with  more  certainty  ;  and  indeed,  it  is  not  my  design  to  substitute 
the  former  of  these  instruments  for  the  latter  ;  I  have  merely  wished 
to  show,  that  among  us,  the  mechanism  of  the  lever  has  been 
generally  misunderstood  ;  that  its  employment,  without  being  indis- 
pensable, is  perhaps  not  to  be  despised  ;  and  that  its  application  is 
too  simple,  too  harmless,  as  compared  with  that  of  the  forceps,  for  it 
not  to  be  had  recourse  to  where  the  head  presents  at  the  perineal 
strait,  and  appears  to  be  arrested  only  by  want  of  action  of  the  wo- 
man's organs  ;  I  will  even  add  that  its  introduction  will  oflen  be  at- 
tended with  the  great  advantage  of  exciting  the  uterine  contrac- 
tions, as  well  as  those  of  the  abdominal  muscles,  and  thereby  of 
accelerating,  at  least  indirectly,  the  termination  of  the  labour,  with- 
out exposing  either  the  woman  or  her  child  to  any  danger  ;  I  am 
happy,  moreover,  in  finding  myself  supported  in  almost  the  whole  of 
this  doctrine  by  M.  Desormeaux. 


ARTICLE  IV. 

Of  the  Fillet. 

1095.  The  noose  consists  of  cloth,  thread  or  silk,  wool,  leather, 
or  cotton,  sometimes  strengthened  by  the  addition  of  bulrushes, 
whalebone,  brass-wire,  or  plates  of  iron  or  steel,  variously  inter- 
laced and  worked,  and  which  was  formerly  applied  to  different  parts 
of  the  foetus,  so  as  to  effect  its  extraction.  The  employment  of 
these  means  is  of  a  very  ancient  date,  and  doubtless  extends  back 
as  far  as  the  age  of  Hippocrates.  Previously  to  the  discovery  of 
the  forceps  and  lever,  the  noose  and  fillet  were  the  only  instruments 
made  use  of  for  the  extraction  of  the  child,  where  there  was  some 
hope  of  preserving  its  life.  Avicenna  recommends  that  they  should 
be  applied  to  the  trunk  ;  but  it  was  particularly  with  a  view  of  fixing 
3L 


k 


483  THE  FILLET. 

it  upon  the  head  that  Mauriceau,  Pugh,  Smellie,  Burton  and  others 
thought  of  a  sort  of  purses,  sheaths,  or  caps,  slings,  and  little  bands, 
which  are  now^wholly  forgotten.  If  the  forceps  is  a  substitute  for  all 
the  various  nets  that  were  formerly  applied  to  the  head,  turning  by  the 
feet,  which  is  better  understood,  and  especially  better  executed  than 
it  was  previously  to  the  last  century,  also  renders  superfluous  all  the 
fillets  which  certain  accoucheurs  used  to  apply  to  the  trunic  for  the 
purpose  of  extracting  it  artificially ;  so  that  at  present  the  noose  is 
merely  a  strip  of  linen,  silk,  or  worsted,  about  an  ell  in  length  and 
an  inch  wide,  by  means  of  which  a  limb  that  has  escaped  from  the 
organs  is  secured,  while  we  proceed  to  search  for  the  other  one,  or 
the  rest  of  the  foetus.  Some  persons,  however,  still  make  use  of  it 
for  the  purpose  of  employing  extractive  force  upon  the  ham,  the 
groin  or  the  axilla  ;  but  as  the  blunt  hook  or  fingers  always  offer 
us  greater  advantages,  they  are  really  useful  only  when  applied  to 
the  wrist  or  ankle  in  arm  presentations  or  in  turning  and  delivery 
by  the  feet. 

1096.  In  order  to  apply  it,  the  strip  is  in  the  first  place  to  be 
doubled  ;  then  a  slip-knot  is  made  upon  it  and  held  apart  with  the 
end  of  the  thumb  and  two  or  three  of  the  fingers  of  the  hand  which 
is  to  take  hold  of  the  foot  or  hand  of  the  foetus  ;  after  this,  it  is 
slipped  up  and  secured  with  the  other  hand,  the  noose  being  fixed 
above  the  articulation  of  the  tarsus  or  carpus ;  it  is  then  given  in 
charge  to  an  assistant,  who  is  to  hold  it,  but  without  pulling  it, 
while  the  operator  proceeds  to  search  for  the  other  parts  that  he 
wishes  to  bring  down  to  the  inferior  strait.  When  both  of  the 
lower  limbs  have  been  brought  down  there  is  no  further  use  for  the 
noose,  provided  it  had  been  secured  upon  the  leg  ;  if  it  is  upon  the 
wrist  it  may  still  be  of  service  in  keeping  the  arm  extended  along 
the  body,  and  consequently  in  favouring  the  delivery  of  the  corres- 
ponding shoulder.  To  conclude,  the  noose  is  a  means  whose  appli- 
cation at  the  present  day  is  confined  within  extremely  narrow  limits, 
and  whose  mechanism  is  too  easily  understood  for  it  to  be  needful 
that  I  should  say  any  thing  further  about  it  here. 


ARTICLE  V. 

Of  the  Locked-Head. 

1097.  According  to  Pcu,  who  was  the  first  writer  to  speak  of  it, 
the  head  is  locked  in  the  passage  whenever  it  is  firmly  held  betwixt  the 


LOCKED-HEAD.  489 

pubis  and  sacrum,  without  being  able  to  advance  or  recede,  and  so 
that  it  is  almost  impossible  to  apply  the  instrument  to  it.  Accord- 
ing to  De  la  Molte,  the  head,  when  locked,  is  griped  by  the  bones 
of  the  pelvis,  like  the  key  stone  in  an  arch.  Ilocderer  presents 
another  view  of  it :  he  thinks  that  in  order  to  constitute  locked 
head,  the  head  must  be  so  embraced  in  the  strait,  or  in  the  excava- 
tion, by  every  point  of  its  circumference,  that  a  lamina  of  metal  or 
the  smallest  probe  cannot  be  passed  between  it  and  the  organs  of 
the  woman.  Baudelocque  says  that  the  head  is  locked,  whenever 
it  is  fixed  at  the  superior  strait  by  the  two  extremities  of  one  of  its 
diameters,  so  that  it  can  neither  advance  under  the  influence  of  the 
natural  powers,  nor  be  forced  back  by  the  hand  of  the  accoucheur. 
Baudelocque's  definition,  which  has  been  adopted  by  all  modern  ac- 
coucheurs, and  slightly  modified  by  M.  Desormeaux,  is  without  con- 
tradiction the  most  correct,  and  may  be  construed  as  follows  :  the 
head  is  locked  in  the  pelvis  whenever  two  diametrically  opposite 
points  of  its  superficies  are  so  compressed  that  it  cannot  possibly 
descend  under  the  influence  of  the  expulsive  power  alone,  and  when 
it  cannot  be  pushed  up  without  the  very  greatest  difliculty.  The 
locked-head,  according  to  the  view  of  it  presented  by  Roederer,  or 
paragomphosis^  cannot  possibly  occur.  Madame  Lachapelle  will 
not  even  admit  the  existence  of  any  species  of  it,  and  tliinks  that  all 
that  has  been  written  under  that  title  ought  to  be  referred  to  vicious 
conformations  of  the  pelvis,  to  bad  positions  of  the  head,  or,  lastly, 
to  powerful  and  permanent  contractions  of  the  uterus. 

1098.  However  this  may  be,  locked-head  has  become  very  rare 
at  the  present  day,  and  De  Bruyn,  who  pretends  to  have  met  with 
eight  hundred  cases  of  it  in  the  course  of  forty  years,  Berkman  and 
Titsing,  who  cite  two  hundred  and  sixty-two  cases  in  nineteen 
years  of  practice,  must  have  had  a  difl'erent  idea  of  it  from  ours. 
It  is  to  roe  evident,  from  the  accounts  given  by  Camper  on  this  sub- 
ject, that  the  Dutch  accoucheurs  gave  the  denomination  of  locked- 
head  to  all  cases  in  which  the  head,  from  being  arrested  in  any  way 
in  the  pelvis,  makes  the  employment  of  Roonhuysen's  lever  necessary; 
so  that  what  they  have  said  concerning  locked-head  has  almost  no 
connexion  with  what  has  since  been  written  by  Baudelocque  under 
that  title.  Dr  Dewees,  who  treats  of  locked-head  upon  the  principles 
of  Baudelocque,  is  astonished  that  he  scarcely  ever  meets  with  it,  and 
thinks  that  the  circumstance  depends  upon  the  American  women 
having  better  formed  pelves  than  the  European  women ;  but  he 
would  probably  hold  a  different  language  if  he  knew  that  Madame 
Lachapelle  never  met  with  it  all,  and  that  but  a  few  instances  of  the 
kind  are  rnet  with  in  the  course  of  a  year. 


•W 


484  LOCKED-HEAD. 

1099.  In  the  first  place,  the  case  where  the  head  is  simply  fixed 
at  tlie  superior  strait,  because  the  liquor  amnii  has  been  long  dis- 
charged and  the  womb  is  closely  contracted  upon  the  body  of  the 
child,  must  not  be  confounded  with  locked-head,  nor  that  case  where 
it  stops  in  the  excavation,  betwixt  two  very  contracted  straits, 
and  after  having  with  great  diificulty  cleared  the  superior  pelvic 
circle,  nor  those  in  which  its  escape  is  prevented  by  the  resistance 
of  the  perineum  or  narrowness  of  the  inferior  strait. 

1 100.  The  head  can  scarcely  become  locked  except  between  the 
pelvis  and  the  sacrum,  at  the  superior  strait ;  further,  in  order  that 
it  may  happen  at  all,  the  conjunction  of  a  great  number  of  condi- 
tions is  required  :  1 .  That  it  shall  present  in  a  direct  manner ; 
2.  In  a  well  formed  pelvis,  it  must  be  of  enormous  size  j  3.  The 
narrowness  of  the  pelvic  cavity  shall  not  exceed  a  certain  degree ; 
and  there  shall  be  a  space  of  two  inches  and  a  half  between  the 
sacrum  and  pubis  for  an  antero-posterior  position,  or  three  inches 
for  a  transverse  position,  for,  locked-head  cannot  take  place  except 
where  the  head  can  get  as  low  down  as  the  level  of  its  greatest 
thickness ;  4.  The  uterine  contractions  shall  have  been  energetic. 

Among  these  conditions  there  is  one  upon  which  I  must  dwell 
for  an  instant.  I  find  a  difficulty  in  conceiving  liow  the  occipito- 
frontal diameter  can  really  get  fixed  in  this  way  in  the  sacro-pubic 
diameter.  The  ends  of  the  lever,  which  it  may  be  considered  to 
represent,  are  too  unequal  for  its  occipital  portion  to  fail  to  come 
down  first,  especially  when  the  efibrts  of  the  woman  react  violently 
upon  it  through  the  intermedium  of  the  vertebral  column  ;  it  seems 
to  me,  then,  much  more  probable  that  it  is  the  occipito-bregmatic 
diameter  that  becomes  locked,  and  that  the  head  may  be  retained 
betwixt  the  sacrum  and  pubis,  as  well  by  any  one  of  the  other  dia- 
meters of  the  occipito-bregmatic  circumference  as  by  the  bi-parietal 
diameter  alone. 

We  may  further  admit,  along  with  M.  Desormeaux,  that  locked- 
head  may  sometimes  take  place  in  the  excavation,  when  the  sacrum, 
flat,  or  nearly  flat,  makes  the  head  pass  along  a  canal  that  gradually 
diminishes  in  size,  as  it  descends,  until  at  last  it  cannot  turn  upon 
its  axis,  nor  advance  nor  recede,  beyond  a  few  lines,  towards  the 
superior  strait. 

1101.  Tumefaction  of  the  lips  of  the  os  uteri  and  external  organs 
of  generation,  and  extreme  degreeof  swelling  of  the  hairy  scalp  and 
overlapping  of  the  cranial  bones,  have  been  given  out  as  signs  of 
locked-head  ;  but  most  of  the  phenomena  may  take  place  without 
the  locked-head,  and  are  therefore  no  sufficient  basis  for  a  sure 
diagnosis. 


LOCKED-HEAD.  485 

The  pathognomonic  sign,  in  these  cases,  is  derived  from  the  fixed- 
ness of  the  head,  which,  in  spite  of  the  energy  of  the  pains,  makes 
no  advances  for  several  hours  together.  While  the  pain  is  present, 
it  seems  to  advance  a  little ;  but  immediately  afterwards  it  rises 
again  up  to  the  same  point  it  occupied  before ;  if  the  accou- 
cheur endeavours  to  push  it  up  again  with  his  hand,  he  finds  that 
it  is  immovable,  and  cannot  succeed  in  dislodging  it  but  with  the 
greatest  difficulty.  It  should  also  be  understood  that,  by  elongating, 
the  head  may  appear  to  descend,  and  approach  near  to  the  vulva, 
although  its  position  does  not  really  undergo  any  alteration.  This 
circumstance  must  be  what  has  so  often  deceived  the  accoucheur, 
making  him  suppose  that  the  superior  strait  was  cleared,  while  in 
fact  the  occipito-bregraatic  circumference  was  not  as  yet  engaged 
in  it.  An  examination  is  made ;  the  vertex  is  found  a  few  lines  from 
,the  vulva,  whence  the  conclusion  is  drawn,  that  it  has  descended 
into  the  excavation :  to  avoid  this  mistake,  and  understand  it,  the 
practitioner  should  remember,  1.  That  the  symphysis  pubis  is  only 
from  eighteen  to  twenty-four  lines  in  depth,  and,  consequently, 
that  the  swelling  of  the  cranial  integuments  may  easily  bring  the 
vertex  down  even  with  the  vulva,  although  the  parietal  protuberances 
are  still  at  the  superior  strait ;  2.  That  the  finger  must  be  carried 
backwards,  especially,  and  not  merely  in  front,  when  we  wish  to 
ascertain  what  part  of  the  pelvis  is  occupied  by  the  head;  and, 
3.  That  the  locked-head  may  take  place  below  the  superior  strait. 

1 102.  There  are  several  degrees  of  this  cause  of  dystocia:  some- 
times the  disproportion  between  the  head  and  pelvis  is  so  small  that 
it  only  results  in  a  somewhat  slower  labour  and  more  fatigue  for  the 
woman ;  at  other  times  it  is  so  great  as  to  render  the  delivery  ex- 
cessively difficult,  but  absolutely  impossible  without  assistance,  pro- 
vided the  contractions  are  well  sustained ;  again,  lastly,  it  is  so  great, 
that  nature  is  absolutely  unable  to  triumph  over  it,  and  the  resources 
of  art  become  indispensably  necessary. 

In  the  case  first  mentioned,  the  locked-head  is  not  very  danger- 
ous, and  ordinarily  is  accompanied  only  by  a  slight  degree  of  irrita- 
tion and  disposition  to  inflammation. 

In  the  second  and  third,  it  constitutes  a  serious  accident,  both  as 
regards  the  mother  and  the  child.  The  pains,  which  follow  each 
other  to  no  purpose,  though  strong  and  frequent,  at  length  end  in  a 
state  of  general  exhaustion  and  inertia,  should  the  woman  even  be 
so  fortunate  as  to  escape  an  attack  of  inflammation  of  the  womb  or 
peritoneum,  a  flooding,  or  convulsions.  The  bladder,  the  rectum, 
the  vagina,  the  urethra,  and  other  sod  parts  in  the  pelvis,  from 


486  LOCKED-HEAD. 

being  long  and  severely  compressed,  may  become  contused,  ulce- 
rated, or  gangrenous,  and  give  rise  to  fistulas  that  are  too  com- 
monly incurable,  or  to  some  other  alteration  equally  terrible.  The 
compression  of  the  nerves,  and  of  the  vessels  in  particular,  may 
give  rise  to  paralysis,  tumefaction,  and  the  infiltration  of  the  lower 
limbs  and  vulva ;  the  symphyses  themselves,  from  being  violently 
distended,  occasionally  run  some  risk,  where  the  expulsive  efforts 
are  vigorously  sustained. 

Ti;e  long  continuance  of  the  labour  after  the  discharge  of  the 
waters,  and  the  direct  action  of  the  contractions  upon  the  body  of 
the  child,  expose  it,  in  the  first  place,  to  the  same  accidents  as  all 
long  and  difficult  labours,  that  is  to  say,  to  asphyxia  and  death. 
Again,  the  head,  particularly  where  the  pelvis  is  badly  formed,  as 
the  sacro-vertebral  angle  is  very  salient,  cannot  adapt  itself  to  the 
straits  or  excavation,  as  in  a  mould,  without  the  brain  itself  under- 
going a  dangerous,  and  sometimes  fatal  compression.  It  may  also 
be  followed  by  fractures,  and  external  or  internal  extravasations, 
lacerations,  &c. 

1 103.  It  is  clear  that,  in  order  to  avoid  so  many  dangers,  the  prac- 
titioner ought  promptly  to  interpose  for  the  assistance  of  the  power- 
less organism ;  but  by  acting  speedily  there  is  risk  of  acting  unne- 
cessarily ;  by  waiting  he  may  lose  the  opportune  moment ;  how  then 
are  these  tv/o  extremes  to  be  avoided  ?  The  well  informed  physi- 
cian will  readily  succeed  in  this  difficulty  by  taking  care  not  to  lay 
it  down  as  a  principle,  as  has  recently  been  done  in  some  medical 
journals,  doubtless  from  oversight,  that  he  must  make  haste  to  ex- 
tract the  child  with  the  forceps,  whether  the  head  is  locked  or  not, 
whenever  it  has  remained  an  hour  or  two  in  the  excavation ;  the 
woman  ought  never  to  be  assisted  in  this  way  until  there  is  a  cer- 
tainty that  the  head  will  not  pass  the  passages  spontaneously,  or  that 
the  delivery  will  not  take  place  without  exposing  the  patient  to  the 
accidents  heretofore  indicated. 

1104.  Turning  by  the  feet,  as  recommended  by  the  ancients, 
must  not  be  performed  merely  because  the  head  is  really  locked ; 
the  slings,  bandages,  and  fillets  would  in  such  cases  be  wholly  in- 
sufficient, and  are  at  present  no  longer  recommended  by  any  body. 
The  lever,  the  spatula,  and  the  separate  branches  of  the  forceps, 
so  much  lauded  by  the  accoucheurs  of  the  last  century,  were  suc-^ 
ccssful  only  because  they  were  employed  in  cases  very  diffijrent  from 
those  which  arc  understood  to  be  locked-head  at  the  present  day. 
Rooniiuyscn's  instrument  is  manifestly  incapable  of  compelling  the 
head  to  descend,  where  there  is  a  disproportion  between  it  and  the 


LOCKED-HEAD.  487 

straits ;  it  might,  at  the  most,  serve  to  dislodge  it  and  give  it  a  more 
favourable  position,  and  in  that  case  it  would  not  be  absolutely 
locked. 

1106.  It  is  otherwise  with  the  forceps,  which  admits  of  the  ef- 
forts of  the  accoucheur  to  be  conjoined  with  those  of  the  womb  and 
abdominal  muscles.  However,  as  the  clams  can  be  applied  only 
upon  the  sides  of  the  pelvis,  some  practitioners  have  objected  that 
by  compressing  the  head  in  a  line  from  right  to  left,  this  instrument 
might  augment  the  pressure  already  experienced  from  front  to  rear, 
instead  of  diminishing  it ;  that  it  is  better  calculated  to  give  rise  to 
locked-head  than  to  relieve  it ;  and  consequently,  more  dangerous 
than  useful ;  but  these  fears,  inspired  by  a  theoretical  view  of  the  sub- 
ject, must  yield  to  facts  ;  besides,  it  is  not  correct  to  say  that  the 
diameters  of  the  head  gain  by  compression  in  one  way  what  they 
lose  in  another  ;  I  repeat  that  I  am  certain  the  forceps  succeeds  in 
extracting  the  locked-head  far  more  by  compelling  it  to  traverse  a 
circle,  which  acts  upon  it  like  a  ring,  than  by  reducing  it  by  means 
of  a  direct  pressure. 

Should  it  not  succeed,  and  the  child  were  ascertained  to  be  dead, 
recourse  should  be  had  to  cephalotomy,  and  then  to  the  crotchet ; 
but  if  the  foetus  were  still  living,  the  operation  of  symphyseotomy 
would  be  indicated,  and  ought  to  be  preferred  to  the  cesarian  ope- 
ration, which,  in  such  a  case,  can  never  be  necessary. 


ARTICLE  VI. 

Of  the  measures  rendered  necessary  by  narrowness  of  the 

Pelvis. 

When  the  pelvis  is  so  deformed  as  to  render  delivery  impossible, 
even  with  the  assistance  of  the  means  I  have  now  passed  in  review, 
there  remain  only  three  kinds  of  resources  for  the  delivery  of  the 
woman  :  1.  To  act  upon  the  foetus  so  as  to  lessen  its  size ;  2.  To 
increase  the  size  of  the  pelvis  ;  3.  To  extract  the  child  by  an  arti- 
ficial passage.  As  these  three  modes  of  delivery  are  excessively 
dangerous,  whether  to  the  mother  or  her  offspring,  it  is  necessary, 
previously  to  putting  them  in  practice,  to  determine  in  what  cases 
they  are  really  indispensable. 

1106.  To  attain  this  object,  the  accoucheur  ought  to  know  the 
exact  dimensions  of  the  head  and  pelvis,  in  those  diameters  which 
conespond  to  the  diameters  that  correspond  to  each  other  in  the 


488  TOO  SMALL  A  PELVIS. 

different  stages  of  labour ;  also,  to  know  how  far  the  head  is  capa- 
ble of  being  reduced,  and  what  amount  of  courage  and  energy  are 
likely  to  be  exhibited  by  the  woman  ;  but  these  notions  can  only  be 
acquired  approximatively.  Notwithstanding  the  numerous  cephalo- 
meters  proposed  by  various  authors,  and  in  spite  of  the  means  re- 
cently indicated  by  M.  Fouilhoux,  We  must  still  depend  upon  the 
finger  for  the  most  certain  result  under  such  circumstances  :  and, 
with  the  exception  of  M.  Flamant,  what  practitioner  is  so  bold  as 
to  dare  to  pronounce  that  the  dimensions  of  a  head  he  has  just 
examined  are,  within  from  two  to  three  lines,  of  precisely  such  or 
such  an  amount  ?  The  degree  of  solidity  of  the  pelvis,  the  form  of 
the  contracted  strait,  and  the  direction  of  its  axes,  also  deserve  the 
most  serious  attentions  :  for  example,  the  symphysis  may  be  soften- 
ed to  such  a  degree  as  to  admit  of  the  bones  sliding  one  over  the 
other,  so  that  one  os  pubis  may  extend  in  front,  while  the  opposite 
coxal  bone  falls  backwards,  which  would  render  the  corresponding 
oblique  diameter  so  much  longer.  According  to  Deventer  and 
Madame  Lachapelle,  the  two  hip  bones  may  also  be  both  carried 
forwards  by  the  forcing  of  the  sacrum  into  the  space  between  them, 
and  thus  give  rise  to  an  unexpected  augmentation  of  the  sacro-pubic 
diameter.  If  the  superior  strait  is  of  the  shape  of  a  figure  8,  or  if 
the  contraction  occupies  only  one  side,  the  head  being  situated 
transversely,  with  the  occiput  towards  the  widest  part  of  the  pelvis, 
may  sometimes  traverse  the  canal  notwithstanding  a  considerable 
degree  of  contraction. 

Where  the  axis  of  the  strait  approaches  that  of  the  spine,  the 
two  extremities  of  the  bi-parietal,  or  the  occipito-bregmatic  diame- 
ter will  be  compelled  to  engage  at  the  same  time,  and  will  require 
a  space  of  about  three  inches.  Should  it,  on  the  contrary,  be  very 
much  inclined  to  the  front,  one  of  the  parietal  protuberances  might 
engage  before  the  other,  so  as  to  give  a  gain  of  three  or  four  lines 
in  the  act  of  passing  through  the  pelvic  circle. 

On  the  other  hand,  a  head  that  is  very  flexible,  and  energetically 
urged  onwards  by  the  uterine  and  muscular  contractions  of  a  vigor- 
ous woman,  may  be  elongated  and  moulded  in  the  passages,  bo  con- 
siderably reduced  (Denman  says,  to  one-third  of  its  original  vio- 
lence), and,  according  to  Baudelocque,  attain  to  the  length  of  eight 
inches,  while  its  thickness  is  proportionably  diminished  ;  it  may  be- 
come so  much  flattened  as  to  pass  through  a  strait  of  two  inches 
and  a  half,  and  recover  its  ordinary  volume  within  the  excavation, 
if  wc  may  give  credit  to  the  assertions  of  Dc  Boer ;  and,  in  all  cases, 
admit  of  the  child's  being  born  alive.  Lastly,  how  many  women  are 
there  who  have  been  fortunate  enough  to  bring  their  children  into 


TOO  SMALL  A  PELVIS.  459 

the  world  without  any  aid,  when  in  their  previous  confinements  they 
could  be  delivered  only  by  symphyseotomy,  the  cesarean  operation, 
or  embryotomy  !  Here,  then,  the  operator  stands  in  need  of  all  the 
integrity  of  a  sound  judgment,  of  prudent  and  sage  counsels,  of 
attention  to  a  thousand  diversified  circumstances,  and  of  proceeding 
only  with  extreme  caution,  if  he  desires  not  to  compromit  the  dig- 
nity of  his  art,  or  the  safety  of  those  beings  who  look  to  him  for  the 
conservation  of  their  existence. 

1 107.  Instead  of  accommodating  itself  to  the  form  of  the  open- 
ings, the  head  may  be  fractured,  or  the  brain  mortally  compressed. 
Long  continued  pressure  upon  the  foetus,  and  particularly  upon  the 
umbilical  cord,  which  most  commonly  gets  down  into  the  excava- 
tion, rarely  permits  it  to  escape  with  its  life  ;  the  woman  herself 
soon  becomes  exhausted  ;  the  bladder  and  other  soft  parts,  against 
which  the  head  presses  with  great  violence,  may  inflame,  be  lacerat- 
ed or  perforated  ;  the  womb,  violently  irritated,  by  its  repeated  con- 
tractions, may  be  ruptured,  aiid  death  ensue.  The  softening  and 
separation  of  the  symphyses  often  leave  behind  them  a  movable  state 
of  the  articulations,  and  a  degree  of  lameness  which  are  at  least 
very  troublesome,  and  where  the  distention  is  carried  to  a  great  ex- 
tent, are  often  followed  by  caries  and  abscesses,  which  sooner  or 
later  terminate  in  the  death  of  the  patient.  There  are,  therefore, 
two  evils,  which  it  imports  to  avoid  with  equal  care;  there  is  a  just 
medium  we  should  endeavour  to  secure. 

1 108.  Let  us  suppose  that  the  application  of  the  forceps  and 
turning  have  been  attempted  in  vain,  or  that  the  pelvis  is  so  deform- 
ed, that  no  greater  confidence  is  to  be  placed  in  those  means  than 
in  the  efforts  of  the  woman,  one  question  presents  itself;  on  whom 
shall  we  operate — the  child,  or  the  mother  ?  Where  there  is  a  cer- 
tainty that  the  pelvis  is  so  contracted  as  to  render  the  delivery  of  a 
mature  and  full  grown  child  either  dangerous  or  impossible,  have 
we  a  right  to  bring  on  abortion,  either  at  an  early  stage  of  preg- 
nancy, or  only  between  the  seventh  and  eighth  months.  Would  it 
not  be  possible,  by  means  of  regimen,  or  a  debilitating  treatment,  to 
oppose,  to  a  certain  extent,  the  development  of  the  fatus,  so  that 
at  full  term  it  shall  be  of  a  very  small  size  ? 

SECTION  1. 

Of  Regimen^  as  a  means  of  enabling  women  with  contracted  pelvis 
to  be  delivered  mtJiout  the  assistance  of  any  surgical  operation. 

1 109.  Were  it  true  that  the  strength  of  the  foetus  while  enclosed 
3M 


490  NARROW  PELVIS. 

in  its  involucra  is  always  in  proportion  to  that  of  the  mother,  nothing 
would  be  more  natural,  nor  better  indicated,  than  to  weaken  a  de- 
formed wonman  during  the  progress  of  her  pregnancy.  But  as  the 
most  robust  women  do  not  always  bear  vigorous  children  ;  as  those 
who  are  naturally  feeble  and  sickly  often  give  birth  to  very  stout 
and  large  ones ;  it  is  to  be  feared  that  the  severest  diet  and  most 
abundant  sangine  evacuations,  would  only  serve  in  such  a  case  to 
incapacitate  the  woman  from  supporting  the  operations  that  would 
notwithstanding  bo  requisite  when  she  should  fall  into  labour.  1 
know  one  person  who,  having  been  delivered  twice  by  means 
of  art,  was  bled  ten  times,  and  confined  to  a  vegetable  diet  dur- 
ing her  third  pregnancy,  with  a  view  of  retarding  the  growth  of 
the  child  ;  this  lady  was,  it  is  true,  exceedingly  weakened  by  it,  but 
the  fcetus  did  not  appear  to  have  been  affected,  and  in  parturition  she 
required  the  same  succours  as  before.  Another  woman  who  had 
two  very  fatiguing  pregnancies,  and  could  not  be  delivered  until 
after  three  days  of  painful  labour,  and  then  by  means  of  the  for- 
ceps, also  became  pregnant  for  the  third  time,  found  herself  less  in- 
commoded than  usual,  and  was,  nevertheless,  delivered  without  as- 
sistance and  without  difficulty,  of  a  child  sensibly  smaller  than  the 
preceding  ones.  I  am  well  aware  that  practitioners  worthy  of  credit 
assert  that  they  have  obtained  directly  contrary  results,  and  T  can 
well  conceive,  as  a  general  rule,  that  by  exhausting  the  woman, 
the  growth  of  her  offspring  will  be  retarded.  But  there  are  so 
many  exceptions  to  this  rule,  and  what  we  gain  on  the  one  hand  is  so 
disadvantageously  compensated  by  the  loss  of  resources  of  which  wc 
deprive  ourselves  on  the  other,  that  1  would  scarcely  venture  to  re- 
commend such  a  course,  except  to  persons  affected  with  a  very 
slight  degree  of  contraction,  and  in  whom  delivery  might,  in  fiict, 
take  place  spontaneously,  should  the  head  of  the  foetus  not  be  too 
large. 

SECTION  2. 

Of  AhoTtion^  brought  on  for  the  purpose  of  rendering  symphyseo- 
tomy or  the  cesarean  operation  unnecessary. 

11 10.  It  was  about  the  middle  of  the  last  century  that  the  most 
distinguished  physicians  of  I^ondon  decided  that,  in  women  affect- 
ed with  deformity  of  the  pelvis,  it  is  proper  to  solicit  delivery  as  soon 
aa  the  viability  of  the  child  is  well  established ;  according  to-  the 
statement  of  Kelly,  Macaulay  was  the  first  person  who  had  recourse 
to  this  operation,   which   resulted   favourably  in   Iiis  hands  :  since 


NARROW  PELVIS.  49 1 

then,  Dr  Barlow  I)as  published  a  memoir  in  which  he  essays  to  prove 
that  artificial  abortion  ought  to  be  substituted  for  the  sigaultian  and 
cesarean  operations  in  all  cases.  Ramsbotham  says  he  brought  on 
abortion  three  times  with  success  in  a  woman  in  whom  the  perfora- 
tion of  the  fcetal  head  had  been  deemed  necessary  in  a  preceeding 
pregnancy  ;  Drs  Davis,  Clough,  Wigand,  and,  very  recently.  Bang, 
and  Dr  Blundell,  have  supported  the  doctrine  advanced  by  Barlow. 
M.  Costa  has  even  inquired  whether  it  is  proper  to  resort  to  it  in 
the  cases  of  women  affected  with  aneurism  of  the  heart. 

1111.  In  France,  this  question  has  been  considered  under  a  point 
of  view  which  has  not  admitted  of  its  value  being  discussed.  It  has 
been  said  that  no  one  has  a  right  to  destroy  a  living  foetus,  even  in 
the  first  months  of  its  existence.  But  delivery,  when  provoked  pre- 
viously to  the  seventh  month,  kills  it  inevitably,  and  rarely  fails  to 
cause  its  death  in  the  seventh  and  eighth.  Besides,  if  it  must  be 
destroyed,  why  not  wait  for  the  term  of  labour ;  by  so  doing  we 
shall  at  least  not  destroy  the  kw  chances  we  have  of  seeing  the 
labour  come  to  a  favourable  conclusion. 

For  my  own  part,  I  confess  I  cannot  possibly  balance  the  life  of  a 
foetus  of  three,  four,  five,  or  six  months,  a  being  which  so  far  scarcely 
differs  from  a  plant,  and  is  bound  by  no  tie  to  the  external  world, 
against  that  of  an  adult  woman  whom  a  thousand  social  ties  engage 
us  to  save  ;  so  that  in  a  case  of  extreme  contraction,  if  it  were  ma- 
thematically demonstrated  that  delivery  at  full  term  would  be  im- 
possible, I  would  not  hesitate  to  recommend  abortion  in  the  first 
months  of  gestation. 

But  the  case  is  difierent  whenever  there  is  a  space  of  two  inches 
and  a  half,  at  least,  between  the  sacrum  and  the  pubis  :  as  in  that 
case  the  ovum  has  been  seen  to  come  away  without  assistance,  and 
the  foetus  born  alive,  the  honour  of  the  art  and  humanity  combine 
to  forbid  the  employment  of  any  destructive  instrument,  or  any 
attempt  that  must  end  in  the  death  of  the  child. 

1112.  The  induction  of  labour  at  the  seventh  month  would  be  par- 
ticularly applicable  where  the  pelvis  is  two  inches  and  a  half  at  least, 
and  two  inches  and  three-quarters  at  the  utmost,  because  it  is  clear, 
from  measurements  taken  by  Madamer  Lachapelle,  that  at  seven 
months  the  bi-parietal  diameter  is  at  most  not  over  three  inches, 
and  may  be  much  less  in  extent ;  which  gives  the  same  chances  as 
if  the  delivery  were  to  take  place  at  term,  and  through  a  strait  of 
three  inches  and  some  lines.  But  how  are  we  to  learn  accurately 
whether  the  foetus  is  viable  ?  If,  for  greater  security,  we  should 
defer  the  operation  till  two  weeks  later,  what  assurance  could  we 


492  NARROV/  PELVIS. 

have  that  the  head  is  not  already  too  large  to  pass  through  the 
straits  ?  And  if  it  can  clear  them  at  eight  months,  is  it  not  probable 
that  it  will  succeed  equally  well  at  the  end  of  the  ninth  ? 

I  am  far  from  thinking  that  the  difficulty  consists  in  penetrating 
as  far  as  the  membranes  so  as  to  rupture  them  ;  nevertheless,  wounds 
of  the  uterus  are  so  dangerous,  that  we  should  always  dread  to  in- 
introduce  an  instrument  into  its  interior:  and  then  it  would  be  a 
strange  misconception  to  suppose  that  abortion  brought  on  in  this 
way  is  not  more  dangerous,  cceteris  -paribus^  than  a  delivery  at  full 
term  :  without  mentioning  the  hemorrhagies,  convulsions,  or  inflam- 
mations of  the  peritoneum,  that  are  but  too  frequently  the  results  of 
the  operation,  we  ought  also  to  expect  the  foetus  to  perish  either 
before  or  soon  after  birth,  in  a  large  majority  of  cases.  Being 
scarcely  viable,  it  is  too  feeble  to  bear  the  contractions  of  the  uterus. 
Although,  after  the  membranes  are  perforated,  the  womb,  some- 
times, enters  powerfully  into  action,  it  also  happens  that  it  remains 
two,  three,  and  even  as  much  as  fifteen  days,  before  it  begins  to 
react  upon  the  product  of  conception  ;  besides,  its  contractions  are 
generally  slow,  feeble,  and  too  far  apart  to  expel  it  when  its  size  is 
considerable. 

Unless  a  very  slight  value  is  attributed  to  the  life  of  the  fcotus, 
this  recourse  is,  then,  of  small  advantage ;  at  least,  previously  to 
making  a  general  precept  of  it,  it  deserves  to  be  maturely  considered 
by  unprejudiced  men,  and  in  a  more  philosophical  way  than  seems' 
to  have  been  done  hitherto  in  England  and  in  Germany. 

1113.  Signs  of  the  death  of  the  fcBtus.  There  is  no  doubt  that 
the  foetus  is  still  living  if  it  moves,  or  if  auscultation  enables  us 
to  hear  the  movement  of  the  heart ;  there  is,  also,  no  doubt  of 
its  being  dead  when  portions  evidently  belonging  to  its  structure,  and 
in  a  state  of  putrefaction,  escape  from  the  organs ;  but  with  the  ex- 
ception of  these  cases,  which  leave  not  the  slightest  uncertainty  upon 
the  subject,  the  question  of  life  or  death  is,  here,  one  of  the  most 
delicate  subjects  in  physiology,  and  one  of  the  most  difficult  of  solu- 
tion of  any  in  tokology.  The  same  thing  takes  place  in  regard  to 
the  death  of  the  fcetus  as  occurs  in  relation  to  the  question  of  preg- 
nancy ;  it  is  announced  by  humerous  signs,  but  they  are  extremely 
variable  and  never  certain.  IIow  could  it  be  otherwise,  inasmuch 
as  it  is  sometimes  impossible  to  pronounce  upon  the  state  of  the 
foetus  that  has  just  been  born,  and  that  is  before  our  eyes  ? 

However  it  may  be,  the  signs  of  death  may  be  divided  into  rational 
and  sensible,  like  those  of  gestation.  The  rational  signs  arc  observed 
before  or  during  labour. 


ARTIFICIAL  ABORTION.  493 

1114.  Previously  to  reaching  the  full  term  the  woman  has  had  a  fall, 
or  has  made  some  violent  movement  or  strong  effort ;  she  has  struck 
her  abdomen  against  some  solid  body  ;  she  has  used  too  much  ardour 
in  coition;  she  has  abandoned  herself  without  reserve  to  vivid  impres- 
sions of  a  moral  kind  ;  she  has  had  a  severe  attack  of  disease,  has 
taken  very  active  medicines  ;  in  fine,  she  has  exposed  herself  to  some 
one  of  the  causes  that  are  capable  of  producing  abortion  ;  in  which 
case  there  is  some  reason  to  presume  that  the  child  is  dead ;  pro- 
vided she  should,  shortly  after  the  accident,  have  had  rigors,  nausea, 
a  sense  of  weight  above  the  middle  of  the  pelvis,  disgust,  horripila- 
tions, or  a  sense  of  coldness  in  the  belly;  if  the  breasts  are  enlarged, 
full  of  milk,  or  shrunk ;  if  the  womb  tends  towards  the  lowest  part 
of  the  body,  and  moves  to  the  right,  left,  or  in  front,  like  an  inert 
mass ;  if  the  fffitus  have  ceased  to  exert  any  active  power;  if  the  abdo- 
men cease  to  enlarge  ;  if  the  mouth  exhale  a  putrescent  odour  ;  if 
there  be  a  general  uneasiness,  or  a  constant  febrile  state,  it  becomes 
extremely  probable  that  the  foetus  is  dead. 

1115.  During  labour  the  death  of  the  foetus  is  announced  by  the 
escape  of  the  meconeum;  by  the  entire  absence  of  motion;  by  a 
putrid  odour  that  escapes  from  the  vagina,  or  rather  from  the  uterus, 
along  with  the  waters;  by  the  diminution  of  the  labour  pains,  and 
by  most  of  the  phenomena  which  I  mentioned  just  now.  There  is 
reason  to  fear  it,  especially,  where  the  amniotic  fluid  has  escaped 
prematurely,  or  at  least  where  it  has  been  long  evacuated,  and  where 
the  position  is  bad,  or  where  the  contractions  of  the  womb  have  in  any 
way  borne  directly  upon  the  foetus  itself.  The  sensible  signs  are  not 
appreciable  until  some  portion  of  the  ovum  itself  can  be  touched 
with  the  finger.  Among  them  is  classed  the  premature  descent  of 
the  cord,  and  the  absence  of  its  pulsation;  inability  to  excite  motion 
in  the  foetus,  although  it  be  raised  up  in  the  womb;  the  escape  of 
shreds  of  the  cuticle;  the  want  of  a  soft  elastic  tumour  on  the 
head;  mobility  of  the  cranial  bones;  the  slight  resistance  offered  to 
pressure  by  the  thorax  or  any  other  part;  the  absence  of  pulsation 
in  the  heart,  &.c. 

But  it  must  be  confessed  that,  perhaps,  not  one  of  these  signs, 
taken  singly,  would  be,  to  a  prudent  man,  a  sufiicient  warrant  to 
pronounce  unhesitatingly  on  the  death  of  the  foetus;  indeed  very  few 
of  them  deserve  much  consideration.  It  is  only  when  united,  when 
constituting  a  whole,  that  wc  are  sometimes  warranted  in  drawing 
pretty  rigorous  conclusions;  the  swelling  of  the  breasts  and  their 
subsequent  shrinking  away  may  occur,  although  the  child  continues 
to  live;  but  this  sign  will,  notwithstanding,  be  very  important,  if  it 
coincide  with  a  majority  of  the  other  rational  signs,  because,  says  M. 


494  NARROW  PELVIS. 

Dubois,  when  the  child  dies,  its  delivery,  regarded  as  the  completion  of 
the  great  act  of  reproduction,  is,  in  some  sort,  effected  for  the  sake  of 
the  economy,  and  the  secretion  of  milk  tends  to  take  place  just  as  if 
the  ovum  were  expelled.  The  same  may  be  said  as  to  the  disagreeable 
load  felt  by  the  woman  in  all  her  movements,  and  the  sense  of  weight 
which  she  experiences  in  the  bottom  of  the  pelvis. 

The  waters  may  have  been  evacuated  for  three,  four,  ten,  fifteen, 
thirty,  and  even  fifty-seven  days,  according  to  Bauhin,  Boer,  and  M. 
Morlanne,  without  being  necessarily  followed  by  the  death  of  the 
foetus;  but  the  contrary  will,  however,  much  more  commonly  be  met 
with.  If  the  meconium  escapes,  and  the  pelvis  is  not  the  presenting 
part,  there  is  great  reason  to  fear  that  it  is  dead,  although  more  than 
one  case  has  been  seen  where,  under  such  circumstances,  the  foetus 
has  been  born  after  several  hours,  strong  and  healthy  :  when  the 
breech  comes  down  first,  there  is  nothing  unnatural  in  the  discharge 
of  the  meconium  which  is  occasioned  by  the  pressure  experienced 
by  the  belly  as  it  passes  through  the  os  uteri,  or  the  straits ;  it  is 
altogether  a  mechanical  effect.  But  when  the  head  is  the  present- 
ing part,  the  same  cause  no  longer  exists,  and,  in  general,  the 
bowels  are  not  evacuated,  unless  the  sphincters,  by  being  weakened, 
like  the  other  muscles,  relax  so  as  to  oppose  no  resistance  to  the 
action  of  the  womb,  which  will  scarcely  take  place  unless  the  child 
is  near  expiring.  Lastly,  the  practitioner  ought  not  on  this  subject 
to  let  himself  be  imposed  on  by  the  muddy  appearance  or  greenish 
colour  of  the  waters ;  for  this  is  an  appearance  often  assumed  by 
them  without  the  meconium  having  any  thing  to  do  with  it. 

1116.  A  living  foetus  sometimes  suddenly  ceases  to  move  alto- 
gether, and  may  remain  several  days  or  weeks,  or  indeed  until  its 
birth,  without  moving,  and  yet  may  not  have  incurred  any  danger ; 
on  the  other  hand,  the  woman  often  supposes  she  feels  it  move  after 
it  has  really  been  dead  for  a  long  time,  and  I  could  relate  noany 
cases  of  the  kind,  one  of  which  I  very  lately  saw  with  Dr  Leseble, 
in  a  young  woman  who  gave  birth  to  a  child  that  had  been  dead  at 
least  four  or  five  days,  although  she  told  us  an  hour  before  the  de* 
livery  that  she  felt  it  move.  But  this  docs  not  prevent  the  sign  from 
being  a  very  important  one  to  the  practitioner  who  knows  how  to 
estimate  it,  and  when,  in  the  course  of  a  long  and  difficult  labour,  the 
motions  of  the  child  are  found  suddenly  to  cease  after  having  been 
agitated  with  more  or  less  violence,  and,  as  it  were,  convulsively, 
there  is  good  reason  to  fear  for  its  safety. 

Portions  of  the  epidermis,  and  some  of  the  hair,  might,  indeed, 
become  detached  from  some  inflamed,  gangrenous  or  ulcerated  point, 
without  the  child  being  dead:  if  this  sign  depended  upon  putrefaclion, 


DEAD  F(ETUS.  495 

it  could  in  no  case  occur  until  after  life  h^d  long  ceased;  in  ^e,  I 
can  scarcely  believe  that  any  one  could  be  deceived  who  should  pay 
a  careful  attention  to  all  the  circumstances. 

1117.  The  odour  that  escapes  from  the  vagina  has  always  seemed 
to  me  to  have  but  little  significancy,  as  long  as  the  membranes  are 
unruptured;  but  after  that,  I  regard  it  as  one  of  the  most  certain 
signs;  it  incontestably  depends  on  the  circumstance,  that  the  air,  by 
gaining  access  to  the  uterine  cavity  while  at  a  high  temperature, 
under  the  influence  of  the  uterine  contractions,  actively  promotes 
the  putrefaction  of  the  liquids  still  remaining  within  the  membranes  ; 
this  odour  at  times  is  rapidly  manifested,  and  may,  in  the  course  of 
a  few  hours,  become  almost  insupportable.  It  would  be  difficult  to 
confound  it  with  any  other  odour,  such,  for  example,  as  that  ex- 
haled from  an  ulcer,  or  a  suppurating  surface  of  any  kind,  and  up  to 
the  present  time  I  have  never  met  with  it  where  the  child  did  not 
afterwards  come  dead  into  the  world. 

1118.  As  to  the  swelling  of  the  hairy  scalp,  since  it  is  produced 
by  the  accumulation  of  fluids  beyond  the  point  of  the  head,  which  is 
strictured  more  or  less  violently  and  for  a  longer  or  shorter  period 
by  the  os  uteri,  or  the  strait  of  the  pelvis,  it  is  evident  that  it  will  not 
form,  provided  the  child  should  be  dead  previously  to  the  rupture  of  the 
membranes  ;  but,  if  the  child  should  not  die  until  after  its  formation, 
it  might  then  continue,  just  as  if  death  had  not  taken  place;  I  do  not 
speak  of  the  over-lapping  and  movableness  of  the  cranial  bones, 
because  they  may  too  easily  lead  us  into  error,  and  also  because 
these  two  phenomena  may  depend  upon  causes  far  too  diverse. 

Where  it  is  possible  to  reach  the  umbilical  cord,  we  can  easily  de- 
termine whether  it  continues  to  pulsate  or  not;  and  I  cannot  well 
conceive  how  this  sign  could  deceive  a  well  informed  practitioner, 
as  to  the  real  state  of  the  child  ;  I  know  that  the  vessels  of  the  cord 
may  suspend  their  pulsations,  during  each  effort  made  by  the  womb 
or  by  the  mother,  without  the  foetus  really  running  any  great  risks  ; 
but  we  should  not  decide  upon  the  child's  death  simply  because  we 
have  examined  the  cord  during  the  presence  of  a  pain,  or  because 
we  have  for  a  moment  felt  it  to  be  without  pulsation.  It  is  only 
after  having  satisfied  himself  that  the  pulsation  is  entirely  abolished 
for  several  minutes,  and  equally  during  the  presence  and  the  absence 
of  the  pains,  below,  as  well  as  above  the  head,  either  free  or  com- 
pressed, that  the  accoucheur  is  at  liberty  to  pronounce  without  fear 
upon  the  state  of  the  foetus.  To  be  still  more  certain,  if  the  head 
had  not  cleared  the  superior  strait,  I  cannot  see  why  the  hand 
might  not  be  passed  up  more  or  less  into  the  womb,  so  as  to  ascer- 
tain whether  the  heart  continues  to  beat,  and  to  touch  the  umbilical 


496  NARROW  PELVIS. 

cord  nearer  its  root,  or  at  some  point  where  it  should  be  free  from 
all  compression. 

1119.  If  then  the  combination  of  all  these  signs,  or  the  chief  of 
them,  were  always  to  be  met  with  where  the  child  is  dead,  there 
will  rarely  be  any  embarrassment  in  giving  a  decision;  but  they  fail 
so  often  when  it  is  indispensable  to  proceed  to  action,  when  tliere  is 
no  time  for  temporising,  that  it  is  easy  to  imagine  how  practitioners 
have  been  led  to  the  performance  of  serious  and  even  mortal  opera- 
tions on  the  mother,  although  the  child  was  actually  dead  ;  and  that 
at  other  times,  the  child  has  been  cut  to  pieces  while  still  full  of  life. 
Hitherto,  medical  men  have  made  only  vain  eflbrts  to  escape  from 
so  distressing  a  position,  and  may  God  grant  that  the  method  lately 
proposed  by  MM.  Bermond,  Baudelocque,  Jr. /and  Toirac,  may 
not  deceive  the  expectations  of  its  inventors.  These  three  physi- 
cians seem  to  have  thought,  at  the  same  time,  and  without  each 
others  knowledge,  that  by  bringing  the  two  extremes  of  an  electric 
circle,  in  the  womb,  in  contact  with  some  given  part  of  the  child,  or 
merely  upon  the  belly,  that  its  muscular  contractions  would  necessa- 
rily be  brought  into  play,  provided  it  were  not  dead.  It  is  a  fact, 
that  both  reason  and  analogy  are  in  favour  of  this  idea;  but  upon  so 
difficult  and  serious  a  subject  we  ought  to  wait  for  a  longer  experi- 
ence and  not  pronounce  lightly. 

1 120.  The  fffitus  is  alive,  and  to  keep  it  so,  we  have  either  to  en- 
large the  openings  through  which  it  has  to  pass,  or  make  new  ones  : 
at  the  commencement  of  the  last  century,  even  when  accoucheurs 
met  with  a  case  of  a  pelvis  so  deformed  us  to  render  delivery  im- 
possible, they  preferred  to  sacrifice  the  child  rather  than  perform 
any  operation  upon  the  mother.  Some  of  the  boldest  of  them,  like 
Mauriceau,  had  immediate  recourse  to  embryotomy,  or  at  least  to 
cephalotomy;  while  others,  as  Delamotte,  being  more  timid,  and 
more  humane,  in  appearance,  but  in  reality  more  barbarous,  pa- 
tiently waited  until  the  child  was  dead  before  they  would  pro- 
ceed to  cut  it  to  pieces.  At  the  present  day,  inasmuch  as  symphy- 
seotomy and  the  cesarean  operation  have  been  successfully  performed 
a  great  many  times,  the  operation  of  embryotomy  is  not  admissible 
until  every  thing  announces  that  the  fcetus  is  dead,  or  tiiat  it  cannot 
live. 


SYMPHYSEOTOMY.  497 

SECTIONS. 

Of  Symphyseotomy . 

1121.  Historical.  Being  persuaded  that  the  articulations  and 
even  the  bones  of  the  pelvis  were  capable  of  being  softened  during 
pregnancy,  Fernel,  S.  Pineau,  and  many  other  old  writers,  conceived 
that  it  would  be  useful  to  favour  their  softening,  in  cases  of  contract- 
ed pelvis,  and  that  tliis  might  be  effected  by  means  of  embrocations, 
cataplasms,  and  topical  or  general  batliing  ;  founding  their  opinion 
upon  these  vulgar  traditions,  which  are  spoken  of  by  Riolan  and  Pare, 
and  which  induce  the  common  people  to  believe  that  in  many  coun 
tries  there  is  a  practice  of  breaking  the  os  pubis  in  young  girls  as 
soon  as  they  are  born,  for  the  purpose  of  rendering  child-birth  more 
easy  for  them;  upon  what  Galen,  in  speaking  of  the  pelvis,  says,  viz. 
non  tantum  dilatari,  sed  et  secari,  tuto  possunt,  ut  internis  succurra- 
tur,  some  modern  physicians  have  supposed  that  the  operation  of 
symphyseotomy  must  have  been  conceived  of  in  the  remotest  anti- 
quity ;  it  is  true  that  CI.  Delacourvee*  mentions  a  deformed  woman 
who  died  previously  to  delivery,  and  in  whom,  after  death,  he  divid- 
ed the  symphysis  pubis  for  the  purpose  of  enlarging  the  pelvis ; 
Plenck  acted  in  the  same  manner  in  1766  upon  another  subject; 
but  it  is  proper  also  to  state  that  no  one  had  formally  thought  of  pro- 
posing the  performance  of  this  operation  in  the  living  subject  with  the 
view  of  facilitating  delivery,  when  Sigault,  who  was  still  a  medical 
student,  made  it  the  subject  of  a  memoir,  which  he  presented  to  the 
Academy  of  Surgery  in  1768. 

1 122.  The  idea  of  symphyseotomy  is,  therefore,  really  due  to  this 
surgeon  ;  the  Academy  was  hardly  willing  to  hear  the  first  proposal 
of  it,  and  Louis,  who  communicated  it  to  Camper,  treated  it  as  a 
ridiculous  project,  engendered  in  a  young  brain  that  was  as  yet  inca- 
pable of  any  reflection  ;  but  not  so  the  celebrated  hoUander,  who,  after 
performing  several  experiments  upon  the  dead  subject,  replied  to  the 
secretary  of  the  academy,  that  at  some  future  day  it  might  be  advan- 
tageously resorted  to.  On  his  part,  Sigault  was  not  disconcerted, 
and  reiterated  the  same  idea  in  his  thesis  at  the  school  of  Angers 
in  1773.  Four  years  afterwards  he  performed  his  operation  in  pre- 
sence of  A.  Leroy,  upon  a  woman  named  Supiot,  and  was  so  for- 
tunate as  to  save  both  the  mother  and  the  child.  This  success  gave 
rise  to  an  extraordinary  degree  of  enthusiasm  ;  the  hundred  tongues 

^      *  De  ^utritione  Fatus  in  uiero  paradoxa.    Dantisci,  lS5o . 
3N 


498  SYMPHYSEOTOMY. 

of  fame,  seemed  insufficient  to  celebrate  the  glory  of  the  author  of 
so  brilliant  a  discovery.  The  faculty  of  medicine  of  Paris  thought 
they  could  not  reward  him  too  highly  by  passing  a  solemn  decree, 
and  causing  a  medal  to  be  struck  in  honour  of  him  ;  so  that  this 
same  Sigault,  whom  the  academy  of  surgery  would  not  deign  to 
hear,  a  few  years  before,  was  soon  proclaimed  the  greatest  bene- 
factor to  humanity,  and  almost  equal  to  the  gods.  Such  exaggera- 
tion as  this  soon  gave  rise  to  a  lively  opposition  amongst  the  sur- 
geons, and  was  the  signal  of  a  combat,  in  which  a  great  number  of 
the  medical  men  of  different  countries  felt  themselves  called  on  to 
take  a  part.  The  Academy  of  Medicine  warmly  supported  the 
opinions  of  Sigault ;  the  Academy  of  Surgery,  as  much  perhaps 
out  of  spite  for  not  having  retained  them  in  its  own  bosom  as  from 
conviction,  continued  to  reject  them  with  no  less  ardour.  Both  par- 
ties were  unjust :  the  dispute  became  scandalous  ;  hbels  were  pub- 
lished, personalities  were  not  spared,  and  being  divided  into  Sym- 
physians  and  Cesareans,  as  they  were  then  called,  the  accoucheurs, 
actuated  by  inveterate  hostility  to  each  other,  were  not  ashamed  to 
keep  up  this  controversy,  equally  curious  and  extraordinary,  until  the 
commencement  of  the  present  century  without  coming  to  an  under- 
standing. Plenck,  Siebold,  A.  Leroy,  Baudelocque,  Saccombe, 
Giraud,  and  Ansiaux,  descended  into  the  arena,  but  without  per- 
ceiving that  the  question  was  illy  stated.  Sigault  in  fact  was  wrong 
to  propose  symphyseotomy  as  a  substitute  for  the  cesarean  opera- 
tion ;  every  body  would  have  been  on  his  side,  had  he  only  propos- 
ed it  as  a  new  resource,  fit  to  enrich  the  art,  an  operation  attended 
with  its  own  peculiar  applications,  advantages,  and  dangers,  and 
which  at  least  renders  cephalotomy  and  the  cesarean  operation  more 
rarely  indispensable.  Weidemann  and  Desgranges  were  the  first 
to  view  it  in  this  light,  and  by  imitating  them,  Thouret  and  M.  Gar- 
dien  have  at  last  put  an  end  to  this  disgusting  polemics,  which  served 
as  an  excuse  and  skreen  for  the  jealousy  and  envious  rivalry  of  all 
the  little  spirits  of  the  period,  to  blacken  the  fame  of  a  great  many 
most  respectable  men. 

But  at  the  present  day,  when  all  the  passions  awakened  on  the  oc- 
casion of  this  quarrel  have  become  extinct,  it  is  an  easy  matter  to 
estimate  the  operation  of  symphyseotomy  at  its  just  value. 

1123.  Mechanism.  When  the  inter-pubal  fibro-cartilage  is  divi- 
ded cither  after  death  or  on  the  living  subject,  the  bones  generally 
separate  about  one  inch,  of  their  own  accord,  and  this  separation 
might,  rigorously  speaking,  bo  carried  artificially  to  the  extent  of 
three  inches,  without  disorganizing  the  posterior  articulations :  when 
the  cartilage  is  divided,  the  coxal  bone  somewhat  resembles  a  lever 


^' 


SYMPHYSEOTOMY.  499 

of  the  first  kind  ;  the  centre  of  motion  is  found  at  the  posterior  part 
of  the  articular  facette  of  the  sacrum  ;  the  posterior  branch  of  this 
lever,  very  short,  and  formed  by  tlie  tuberosity  of  the  ilium,  is  drawn 
backwards  and  towards  the  median  line  by  the  posterior  sacro-iliac 
ligaments  ;  its  anterior  branch,  which  is  very  much  bent,  (coudee) 
separates  (from  the  corresponding  pubis)  in  proportion  to  its  excess 
of  length  over  the  branch,  which  represents  the  power;  the  fore  part  of 
each  posterior  symphysis  becomes  somewhat  open  ;  the  fibrous  tissue 
which  covers  them  yields,  is  elongated,  stretched,  and  detached  ; 
the  elastic  cushion  which  is  behind  them  becomes  relaxed,  and  the 
sacrum  compressed,  from  behind  forwards,  tends  to  escape  towards 
the  interior  of  the  pelvis.  When  the  surgeon  adds  still  more  to  the 
separation  of  the  pubes  by  pressing  upon  the  cristae  of  the  ileum, 
the  power  is  transferred  to  the  anterior  branch  of  the  lever,  and  it 
is  evident,  that  thenceforth  no  very  violent  effort  would  be  required  to 
tear  away  all  the  bonds  of  the  posterior  articulations.  This  is  the 
situation,  particularly,  where  the  displacement  of  the  sacrum  in  front 
must  cause  the  increase  of  the  length  of  the  antero-posterior  diameter 
to  disappear  as  fast  as  it  tends  to  take  place.  In  the  empty  pelvis  and 
upon  pieces  of  paper  this  is  really  the  case  ;  but  in  the  living  subject, 
while  the  pubes  are  separating,  the  child's  head  pushes  the  sacrum 
backwards,  beyond  its  natural  limits,  rather  than  admits  of  its 
advancing  into  the  excavation.  Nevertheless,  it  would,  in  most 
women,  be  dangerous  to  separate  the  ossa  pubis  from  each  other 
more  than  one  or  two  inches  :  we  could  not  go  beyond  that  without 
lacerating  the  loose  and  abundant  cellular  tissue  of  the  excavation, 
the  anterior  sacro-iliac  ligaments,  and  part  of  the  posterior  ones, 
without  giving  rise  to  the  most  violent  pain,  and  causing  the  most 
redoubtable  inflammations,  unless  the  symphyses  should  happen  to 
be  already  very  much  softened  beforehand,  under  which  circum- 
stance it  is  not  likely  that  symphyseotomy  would  ever  be  required. 
Since  you  agree,  say  the  antagonists  of  the  operation,  on  the  one 
hand,  that  it  is  not  prudent  to  attempt  a  greater  degree  of  separation 
than  two  inches  or  two  inches  and  a  half;  and  on  the  other,  that 
the  antero-posterior  diameter  is  never  enlarged  more  than  two  lines 
for  one  inch,  four  lines  for  two  inches,  and  six  or  eight  lines  for 
three  inches*  of  separation,  it  is  manifest  that  you  can  depend  upon 
only  three  or  four  lines  of  ampliation  of  the  pelvis  :  now,  is  it  right 
that  we  should  perform  so  serious  an  operation  for  "the  purpose  of 
gaining  only  three  lines,  and  perhaps  not  more  than  two  ?  This 
argument  at  first  seemed  almost  unanswerable  :  then  it  was  said  in 

*  Boer  even  asserts  that,  when  carried  to  the  extreme,  this  separation  can  never 
give  more  than  three  lines  additional  to  the  antero-posterior  diameter. 


500  SYMPHYSEOTOMY. 

reply  :  doubtless  we  obtain  an  elongation  of  only  th -ee  lines  for  the 
antero-posterior  diameter,  but  by  engaging  in  the  void  space  between 
the  separate  pubes,  the  parietal  protuberance  or  projecting  part  of 
the  occiput  will  abstract  at  least  three  or  four  lines  from  the  diame- 
ters of  tlie  head,  so  that  we  gain  at  least  half  an  inch.  In  speaking 
after  this  fashion,  authors  have  forgotten  that  the  occiput  or  the 
parietal  protuberance  is  commonly  found  behind  the  body  of  the 
pubis  or  acetabulum,  and  not  behind  the  posterior  face  of  the  sym- 
physis. But,  further,  this  last  disposition,  in  its  turn,  gives  great 
advantages  in  the  operation,  and  I  am  astonished  that  the  authors 
have  scarcely  mentioned  it.  I  mean  that,  if  the  antero-posterior 
diameter  is  augmented  only  two  or  three  lines,  the  oblique  ones  will 
be  increased  by  at  least  six  lines ;  and  as  the  occipito-frpntal,  breg- 
matic  and  bi-parietal  diameters  are  not  directed  from  front  to  rear, 
but  obliquely,  it  follows,  in  fact,  that  the  section  of  the  symphysis 
appears  to  be  less  limited  in  its  applicability  than  has  been  generally 
imagined.  The  researches  of  M.  Desgranges  prove  that  it  permits 
the  oblique  and  transverse  diameters  of  the  pelvis  to  enlarge  to  the 
extent  of  near  an  inch  ;  that  at  the  inferior  strait  particularly,  it  would 
procure  a  considerable  ampliation,  and  that  upon  this  subject  there 
is,  such  is  my  opinion,  a  want  of  some  additional  experiments. 

1124.  Advantages  and  disadvantages.  The  operation  of  sym- 
physeotomy, therefore,  seems  to  be  applicable  in  all  cases  where  an 
increase  of  space  to  the  amount  of  four,  five,  or  six  lines  would  per- 
mit the  head  to  pass  ;  for  example,  in  all  cases  where  the  forceps  is 
insufficient,  and  where,  nevertheless,  the  smallest  diameter  of  the 
strait  exceeds  two  inches  and  a  half.  But  as  it  is  seldom  possible, 
in  the  living  subject,  to  ascertain  how  far  the  head  is  susceptible  of 
reduction  under  pressure,  and  whether  the  strait  is  two  inches  and 
eight  lines  rather  than  two  inches  and  a  half,  it  has  happened  that 
the  accoucheur,  finding  a  difiiculty  in  marking  the  point  where  the 
section  of  the  pubis  becomes  indispensable,  and  that  where  it  can 
no  longer  suflice,  has  generally  decided  in  favour  of  the  cesarean 
operation,  whenever  the  absolute  necessity  of  doing  something  to 
save  the  child's  life  has  been  ascertained.  As  to  the  dangers  of  the 
operation,  it  appears  to  me  difficult  to  prevent  them,  where  the  volume 
of  the  head  requires  a  considerable  separation  of  the  pubes,  and 
wherever  the  pelvic  articulations  arc  naturally  very  little  relaxed. 
Even  could  we  dispense  with  acting  on  the  liips  or  thighs,  the  child, 
nevertheless,  must  pass  through,  and,  whether  we  extract  it  with 
the  forceps  or  by  turning,  or  whether  the  contractions  suffice  for  its 
expulsion,  nothing  seems  able  to  hinder  the  head,  as  it  passes  through 
the  contracted  strait,  from  violently  distending  the  posterior  articu- 


SYMPHYSEOTOMY.  501 

lations,  and  even  lacerating  Ihem  if  its  dimensions  exceed  those  of 
the  circle  through  which  ft  must  traverse. 

I  am,  however,  far  from  thinking,  along  with  Denman,  Lauverjat, 
Hunter,  Osborn,  and  Dr  Dewees,  that  it  ought  to  be  rejected  in  all 
cases  ;  I  merely  wish  to  show  that  its  partisans,  in  their  representa- 
tions, have  singularly  lessened  its  dangers,  and  exaggerated  its  ad- 
vantages. 

It  is  the  only  means  of  safety  that  can  be  resorted  to  :  1.  Where 
the  head  is  locked  in  the  excavation,  after  having  passed  through  a 
very  contracted  superior  strait ;  2.  Where  the  head  has  cleared  the 
OS  uteri,  and  is  arrested  by  narrowness  of  the  inferior  strait ;  3. 
Where  the  trunk  is  delivered,  the  life  of  the  child  unquestionable, 
and  it  is  impossible  for  the  head  to  get  through  the  natural  passages. 
In  these  three  cases,  it  is  preferable  to  the  cesarean  operation,  even 
after  the  death  of  the  woman  ;  and  that,  because  it  would  be  almost 
impossible  to  avoid  killing  the  child  by  attempting  to  extract  it  by 
the  abdominal  opening. 

1125.  Further,  it  offers  unquestionable  advantages  wherever 
the  contraction  affects  the  transverse  and  oblique  diameters ; 
where  it  exists  at  the  inferior  strait ;  when  it  depends  on  barrure^ 
an  exostosis,  any  solid  tumour  situated  laterally,  or  oh  a  pro- 
tuberance of  the  acetabulum  ;  the  same  holds  good  of  locked- 
head,  whether  of  the  species  called  by  Roederer  paragom- 
phosis,  or  whether  the  head  is  pinched  at  the  two  extremities  of  its 
bi-parietal  or  occipito-frontal  diameter,  or  in  any  other  way  that 
prevents  it  from  descending,  and  from  being  easily  pushed  upwards  ; 
and  lastly,  whether  this  locked-head  be  understood  after  the  manner 
of  Baudelocque,  of  Madame  Lachapelle,  or  of  M.  Desormeaux,  pro- 
vided always,  that  the  inferior  strait  be  not  extremely  contracted  ;  it 
is  manifest,  further,  that  if  the  elongation  of  the  sacro-pubic  diame- 
ter, produced  by  the  section  of  the  pubis,  must  be  so  much  the 
greater  in  proportion  as  the  contraction  of  the  pelvis  is  so  much  the 
more  considerable,  as  maintained  by  Giraud  and  Ansiaux,  the  very 
contrary  may  also  happen,  as  has  been  well  observed  by  Boer  and 
by  Madame  Lachapelle. 

1126.  To  perform  this  operation,  it  is  necessary  :  1.  That  the 
foetus  shall  be  living,  for  notwithstanding  what  M.  Gardien  says,  where 
symphyseotomy  is  indicated,  should  the  child  be  dead,  we  ought 
to  prefer  the  operation  of  cephalotomy,  which  would  always  suffice 
in  that  case  ;  2.  That  the  presentation  shall  be  natural,  and  that, 
as  far  as  possible,  we  shall  not  be  compelled  to  extract  the  foetus  by 
the  feet,  because  turning  too  frequently  occasions  its  death  ;  3. 
That  the  os  uteri  shall  be  largely  dilated  :  for  otherwise  there  could 
be  no  certainty  that  the  operation  is  indispensable,  and  moreover,  we 


502  SYMPHYSEOTOMY. 

might,  after  performing  it,  find  it  impossible  to  terminate  the  deli- 
very with  the  necessary  rapidity ;  4.  That  the  woman  shall  be 
young  enough  to  obviate  all  fears  in  relation  to  anchylosis  of  the 
pelvis. 

1127.  Manner  of  operating.  The  patient,  being  placed  upon  an 
operation  table,  or  on  the  bed,  in  the  same  manner  as  for  the  ap- 
plication of  the  forceps,  having  her  thighs  and  legs  slightly  flexed, 
and  properly  separated,  an  assistant  must  hold  her  shoulders,  and 
two  others  take  charge  of  her  knees,  while  a  fourth  stretches  the 
skin  of  the  belly,  and  a  fifth  is  prepared  to  hand  the  operator  what- 
ever may  be  required. 

1128.  Situated  to  the  right  or  betwixt  the  legs  of  the  patient, 
the  surgeon,  with  a  convex  and  very  sharp  bistoury  makes  an  inci- 
sion, which  should  commence  a  little  above  the  symphysis  and  ex- 
tend close  to  the  clitoris  ;  this  incision  divides  the  skin,  previously 
shaved,  and  all  the  soft  parts  that  compose  the  mons  veneris  ;  being 
parallel  to  the  median  line,  it  ought  to  fall  as  nearly  as  possible  upon 
the  centre  of  the  articulation  ;  at  its  lower  part,  however,  it  is  well 
to  give  it  a  slight  inclination  to  one  side,  between  the  top  of  the 
greater  and  lesser  labium,  and,  even  to  separate  one  of  the  roots  of 
the  clitoris  from  the  ramus  of  the  pubis,  for  the  purpose  of  avoiding 
dangerous  lacerations  at  a  later  stage  of  the  process.  There  can 
be  none  but  very  small  arteries  to  tie,  unless  the  internal  pudic 
should  be  divided  by  incautiously  carrying  the  incision  too  far  down- 
wards. For  the  purpose  of  dividing  the  cartilage,  some  have  re- 
commended that  we  should  act  from  below  upwards,  others  from 
above  downwards,  and  several  from  behind  forwards,  or  from  within 
outwards,  and  most  writers  from  before  backwards.  There  are 
some  who  have  made  use  of  a  bistoury,  a  sort  of  scalpel  en  ron- 
dache,  of  the  pliable  knife  of  Aitken,  of  a  probe-pointed  bistoury, 
or  a  common  bistoury,  the  point  of  which  M.  Gardien  recommends 
to  be  covered  by  the  point  of  the  nail  of  the  left  fore  finger,  so  as 
to  prevent  any  injury  to  the  internal  organs.  In  such  a  case  every 
man  ought  to  be  allowed  to  choose  the  instrument  that  pleases  him 
best ;  for  my  own  part,  I  think  that  in  this,  as  in  other  cases,  regard 
is  rather  to  be  paid  to  the  hand  that  acts  than  to  the  shape  of  the 
bistoury,  and  that  the  only  essential  quality  of  the  operating  knife 
is  strength  and  sharpness.  The  safest  way  is  to  cut  the  sym- 
physis from  above  downwards,  and  from  the  cutaneous  surface  to 
the  pelvic  surface  of  the  symphysis.  The  incision  ought  to  be  ex- 
tended upwards  half  an  inch,  or  even  a  whole  inch,  along  the  linea 
alba.  To  avoid  the  risk  of  wounding  the  bladder,  or  urethra,  as 
has  happened  with  some  surgeons  who  went  at  one  stroke  quite  to 
the  head  of  the  child,  fhrougli  the  bladder  and  womb,  I  think  it  will 


SYMPHYSEOTOMY.  503 

always  suffice  to  hold  the  blade  of  the  bistoury  at  some  distance 
from  its  point  with  the  left  finger  and  thumb,  while  we  make  its  cut- 
ting edge  act  with  the  right  hand  :  with  the  view  of  still  more  cer- 
tainly avoiding  the  bladder  and  urethra,  the  catheter  should  be 
introduced  early,  or  at  least  previously  to  commencing  the  second 
stage  of  the  operation.  By  this  means  the  bladder  is  emptied,  and 
the  catheter  serves  to  push  the  urethra  a  little  to  the  right,  while  the 
incision  is  inclined  slightly  to  the  left  side  of  the  sub-pubal  ligament. 
When  the  ligamentous  matter  is  almost  divided,  the  precautions  are 
to  be  redoubled  ;  the  cutting  should  now  be  done  almost  wholly  by 
touches  with  the  point  of  the  knife,  and  it  is  to  be  laid  aside  as  soon 
as  we  find  no  more  resisting  and  elastic  material  to  divide. 

1129.  Frightened  with  the  imaginary  disorders  which  might  be 
produced  by  the  access  of  the  air  into  the  articulation,  Alphonse 
Leroy  advised  that  the  operation  should  be  divided  into  two  stages: 
for  that  end  M.  Lescure,  his  pupil,  thinks  that  an  incision  of  nine 
or  ten  lines  should  first  be  made  through  the  skin;  then,  after  having 
divided  one-third  of  the  cartilage  with  extreme  gentleness,  that  we 
should  return  and  prolong  the  section  of  the  ligaments  as  far  as 
the  clitoris,  and  afterwards  proceed  to  divide  the  remainder  of  the 
cartilage,  "  without  minding  the  blood  that  escapes  from  the  small 
external  pudic  vessels,  this  section  is  performed,  says  he,  very  slowly, 
and  by  carefully  feeling  the  cartilage." 

Others  have  supposed  they  could  more  certainly  attain  the  same 
end,  by  dividing  the  skin  only  above  and  below  the  symphysis,  or, 
even  only  to  the  extent  of  a  few  lines  opposite  its  middle  portion, 
which  would  surely  render  the  section  of  the  ligament  very  diflicult; 
but  at  the  present  day  these  ill  founded  fears  are  dismissed  :  it  is  uni- 
versally known  that  the  accidents  that  too  often  follow  the  operation 
of  symphyseotomy  are  unconnected  with  the  action  of  the  air  upon 
the  cartilage;  and  further,  that  such  modifications  in  the  mode  of 
conducting  the  operation  would  in  no  wise  prevent  it. 

1130.  Previously  to  commencing,  it  is  important  to  make  sure  of 
the  spot  occupied  by  the  articulation;  for  when  the  pelvis  is  deformed, 
it  is  not  uncommon  to  find  it  deviated  so  far  to  one  side  as  that  the 
operator  has  on  more  than  one  occasion  fallen  on  the  body  of  the 
bone,  instead  of  uncovering  the  cartilage  itself. 

Should  it  so  happen  that  the  symphysis  is  found  ossified,  as  in  the 
pelvFs  mentioned  by  Wiedemann  and  Lauverjat,  and  as  Boer  and 
Madame  Lachapelle  inform  us  is  often  the  case,  there  would  be  so 
small  a  chance  of  obtaining  even  a  tolerably  large  opening,  that  in- 
stead of  sawing  the  articulation,  as  was  done  by  Siebold,  I  should 
prefer  to  have  recourse  to  the  cesarean  operation.     By  applying  the 


504  SYMPHYSEOTOMY. 

saw  beyond  the  symphysis,  upon  the  very  body  of  the  bone,  accord- 
ing to  the  counsel  of  M.  Desgranges,  the  operation  would  not  be  ren- 
dered either  more  or  less  dangerous;  for  the  difficulty  exists  behind, 
in  the  sacro-iliac  articulations,  and  not  in  front. 

1131.  Immediately  subsequent  to  the  division  of  the  cartilage, 
the  posterior  branch  of  the  bent  lever,  formed  by  the  coxal  bone 
being  acted  on  by  the  elasticity  of  the  posterior  sacro  iliac  ligaments, 
occasions  a  separation  of  from  six  to  twelve  lines  between  the  pubes. 
This  separation  must  necessarily  vary,  according  to  the  degree  of 
contraction  of  the  pelvis,  and  the  rigidity  or  softness  of  the 
symphyses  :  if  it  is  sometimes  effected  in  equal  proportions  by  both 
of  the  bones,  there  must  also  be  cases  where  one  is  much  more  con- 
cerned in  it  than  the  other.  Be  this  as  it  may,  I  find  it  difficult  to 
understand  how  it  can  go,  spontaneously,  to  such  an  extent  as  to 
prove  dangerous,  or  that  it  is  worth  while  to  restrain  it  by  securing 
the  hips  previously  to  the  conclusion  of  the  operation.  On  the 
contrary,  to  carry  it  to  a  sufficient  extent,  it  is  almost  always  requi- 
site slowly  and  moderately  to  press  the  hips  from  within  outwards, 
and  from  before  backwards,  or  carefully  to  separate  the  woman's 
ttiigbs. 

1132.  Unhappily,  when  the  operation  is  terminated,  the  delivery 
is  still  far  off.  If  the  contractions  are  energetic  and  well  sustained, 
the  delivery  is  entrusted  to  the  natural  powers,  to  which  also  it  would 
doubtless  be  better  to  refer  the  care  of  separating  the  divided 
symphysis  to  the  required  extent;  but  if  the  womb  does  not  react,  if 
the  labour  grows  languid,  or  any  circumstance  arises  demanding 
the  prompt  extraction  of  the  foetus,  we  are  obliged  to  apply  the  for- 
ceps, or  turn  the  child,  and  that  conformably  to  the  principles  that 
have  already  been  laid  down;  remembering,  further,  that  turning 
causes  the  child  to  incur  the  greatest  risks,  and  that  it  was  for  the 
preservation  of  its  life  that  the  mother  was  subjected  to  the  section 
of  the  pubis. 

I  should  so  greatly  fear  to  bring  down  the  feet  in  such  a  case, 
that,  unless  they  had  originally  presented,  I  would  without  hesitation 
give  the  ergot  to  excite  the  uterine  contractions,  and  would  attempt 
'*^e  employment  of  the  forceps,  even  should  the  head,  still  engaged 
■if  in  the  superior  strait,  be  found  to  be  situated  transversely.  During 
this  part  of  the  operation  it  would  probably  be  necessary  to  support 
the  hips  or  whole  pelvis,  either  with  the  hands  or  a  suitable  bandage, 
so  as  to  prevent  the  articulations  from  being  too  much  lacerated  by 
the  cxccntric  pressure  of  the  foetal  head  or  the  efforts  of  the  ac- 
coucheur. 

1 133.  Dressing.     When  the  delivery  is  complete  the  woman  is 


SYMPHYSEOTOMY.  505 

to  be  cleansed;  the  pubes  are  brought  into  contact  with  each  other; 
some  lint,  spread  with  cerate,  and  some  compresses  are  to  be  placed 
over  the  womb;  a  body  bandage  passed  round  the  pelvis  keeps  every 
thing  in  place,  and  should  be  sufficiently  tight  to  prevent,  at  least  to  a 
certain  extent,  anew  separation  of  the  bones  from  taking  place;  the 
patient  being  now  put  to  bed,  ought  to  lie  on  her  back,  and  be  kept 
in  a  state  of  the  most  perfect  rest;  her  thighs  especially  ought  not 
to  move  for  six  weeks  or  two  months,  a  period  of  time  which  is  in- 
dispensably necessary  for  the  consolidation  of  the  symphyses;  she  is 
also  to  be  kept  upon  the  regimen  proper  in  serious  operations,  and  if 
any  accidents  make  their  appearance,  they  must  be  vigorously  com- 
bated. 

The  discharge  of  the  lochia3  must  be  carefully  attended  to,  and  if 
they  threaten  to  disappear  too  soon,  emollient  or  detergent  injec- 
tions should  be  thrown  into  the  vagina,  and  the  woman  should  be 
advised,  if  she  can,  to  suckle  the  child,  and  care  must  be  taken  to 
preserve  the  lips  of  the  wound  in  constant  contact.  When  the  term 
of  cure  approaches,  motion,  and  particularly  walking,  should  not  be 
allowed,  except  with  great  reserve.  Should  there  still  remain  any 
mobility  and  pain  in  the  pelvis,  recourse  must  again  be  had  to  rest 
for  a  longer  or  shorter  period,  and  it  often  happens  that  walking 
and  standing  cannot  be  permitted  without  danger  for  three  or  four 
months.  Doubtless  nothing  can  be  more  desirable  than  the  conso- 
lidation of  the  divided  symphysis ;  but  there  have  been  women  in 
whom  it  could  not  be  obtained,  and  who  were  notwithstanding  able 
to  walk,  stand,  and  leap,  without  sensible  inconvenience,  which  is 
to  be  explained  upon  the  supposition  that  the  posterior  symphyses 
had  acquired  a  great  degree  of  firmness.  MM.  Mansuy  and  Du- 
bois have  each  related  a  case  of  this  sort.  A.  Leroy  and  M.  Les- 
cure  even  go  so  far  as  to  say  that  it  ought  to  be  promoted  by  omit- 
ting any  bandage  round  the  pelvis ;  they  say,  and  perhaps  they  are 
not  wholly  wrong,  that  the  space  between  the  symphysis  fills  with  a 
cellulo-fibrous  tissue,  which  does  not  prevent  the  articulation  from 
being  firm,  and  also  allows  the  woman  to  bear  children  subsequently 
with  much  greater  facility. 

1134.  Results.  Upon  the  whole,  when  we  consider  that  out  of 
forty-three  women  who  have  undergone  the  operation  of  symphy- 
seotomy fourteen  died ;  that  several  remained  crippled  for  life,  par- 
ticularly the  two  spoken  of  by  Madame  Lachapelle,  and  who  were 
operated  on  at  the  Maternity  ;  that  in  some  of  them  the  operation 
was  not  indispensably  necessary,  since,  as  we  find  in  Baudelocque's 
work,  that  they  were  afterwards  delivered  without  assistance  or 
difficulty ;  that  most  frequently  the  child  has  not  been  saved,  and 
30 


506  SYMPHYSEOTOMY. 

that,  in  fact,  it  must  in  a  majority  of  cases  perish  under  the  opera- 
tion of  turning  or  the  forceps,  which  we  are  almost  always  obliged 
to  try;  lastly,  as  observed  by  Lauverjat,  that  in  eighteen  opera- 
tions, twenty-one  individuals,  mothers  or  children,  perished  ;  that  in 
two  cases  it  was  found  necessary  to  have  recourse  to  the  cesarean 
operation ;  that  five  were  followed  by  incontinence  of  urine,  and  one 
by  claudication  ;  that  in  the  thirty-four  cases  mentioned  by  Baude- 
locque,  only  eleven  children  were  saved ;  when  we  consider,  I  say, 
all  these  dangers,  and  compare  them  with  the  advantages  derived 
from  it  in  the  most  successful  cases,  it  is  difficult  not  to  concur  with 
M.  Desormeaux  in  regarding  the  section  of  the  symphyses  as  being 
in  fact  scarcely  less  serious  than  the  cesaraen  operation,  and  that 
its  employment  ought  to  be  restricted  within  pretty  narrow  limits. 

1135.  Catolica' s  operation.  If  I  understand  correctly  what  was 
told  me  by  Professor  Vulpes,  it  would  appear  that  Dr  Catolica  of 
Naples  has  suBStituted  another  operation  for  that  of  symphyseotomy, 
which,  properly  speaking,  is  but  a  modification  of  the  one  already 
proposed  by  M.  Desgranges  of  Lyons.  Instead  of  dividing  the  car- 
tilage, he  proposes  that  the  body  and  ramus  of  the  pubis  on  each 
side  should  be  divided  between  the  two  oval  foramina,  as  was  recom- 
mended by  Aitken.  In  this  way,  the  sacro-iliac  symphyses  remain 
uninjured  ;  no  risk  of  wounding  the  bladder  or  urethra  is  incurred  ; 
the  cellular  tissue  of  the  pelvis  is  scarcely  stretched,  and  the  conso- 
lidation is  easily  obtained  ;  there  is  no  fear  of  abscess,  caries,  fistulse, 
claudication  nor  peritonitis,  and  a  considerable  ampliation  of  the 
sacro-pubic  diameter  is  obtained.  I  am  not  sufficiently  acquainted 
with  the  reasons  of  the  author  to  enable  me  to  combat  or  approve 
the  operation,  and  until  I  shall  have  become  more  fully  informed, 
shall  content  me  with  the  little  I  have  now  said  concerning  it. 

SECTION  4. 

Cf  the  Cesarean  Operation.,  {Hysterotomy.,  Hysterotomotocia^  Cesa- 
rean Delivery.,  Gastro- Hysterotomy). 

The  denomination  of  cesarean  section  is  given  to  an  openihg 
made  into  the  belly  and  womb  for  the  purpose  of  extracting  the 
fcBtus  when  it  cannot  be  delivered  through  the  natural  passages; 
since  the  time  of  Simon  its  application  has  been  further  extended 
to  the  incision  or  incisions  which  it  is  sometimes  necessary  to  make 
in  the  cervix  of  the  uterus,  with  the  view  of  facilitating  the  passage 
of  the  head  through  it. 

1 136.  Historical.     Being  lost,  as  it  were,  in  the  night  of  time, 


CESAREAN  OPERATION.  507 

the  origin  of  this  operation  has  not  as  yet  been  precisely  ascertained 
by  any  one.  In  the  fabulous  ages,  it  was  said  that  a  foetus,  the 
son  of  Jupiter,  was  extracted  from  the  belly  of  Semele  by  Mer- 
cury. The  Romans  made  the  same  statement  concerning  Escula- 
pius,  who  was  extracted  from  the  belly  of  his  mother  by  Apollo, 
aft§r  she  had  been  already  placed  on  the  funeral  pile  destined  to 
consume  her.  Virgil  also  says  that  Lycus  came  into  the  world  in 
the  same  manner.  These  vague  traditions,  a  passage  in  Pliny,  and 
certain  Roman  laws,  induce  a  belief  that  the  cesarean  operation 
must  have  been  employed  in  the  most  remote  ages.  M.  Mansfield, 
in  a  work,  an  extlact  of  which  is  contained  in  the  Bulletin  des 
ScieTices  Alcdicales,  attempts  to  prove  that  it  was  practised  even  by 
the  Jews.  It  is  said  in  the  Talmud  and  the  Mischajoth  that  a  child 
born  by  a  section  of  the  belly  has  not  the  rights  of  primogeniture. 
Jaschi  has  described  it  in  his  commentary  on  the  Nidda,  and  says 
that  women  who  have  undergone  it  are  not  compelled  to  perform  the 
forty-days  purification.  There  is,  however,  no  certain  proof  that  it 
was  performed  upon  a  living  woman  anteriorly  to  the  year  1520, 
unless  we  admit  as  authentic  the  case  of  the  lady  at  Craon,  who, 
according  to  the  statement  of  Goulin,  was  subjected  to  the  section 
of  the  belly  in  1424,  and,  as  well  as  her  child,  survived  the  operation. 
The  ancient  Greek  and  Latin  physicians  make  no  mention  of  it 
whatever.  Guy  de  Chauliac,  who  seems  to  have  first  described  it, 
founding  his  opinion  upon  the  following  passage  of  Pliny,  (Auspica- 
tins,  enectd  parente,  gignuntur,  sicut  Scipio  Africanus  prior  natus, 
primusque  Cmsus,  Cceso  matris  utero,  dictus ;  qua  de  causd,  Ccesones 
appellati.  Simili  modo  natus  est  Manlius  qui  Carthaginem  cum 
exercitu  intravit),  believes  that  it  took  its  name  from  Julius  Caesar; 
others,  on  the  contrary,  think  that  the  general  and  his  family  took 
their  name  from  the  operation.  Bayle  remarks  that  Aurelia,  the 
mother  of  Caesar,  was  still  living  when  he  went  to  Britain,  and  con- 
sequently that  the  story  related  by  Pliny  ought  to  l)e  rejected  as 
fabulous;  the  researches  of  Weidemann  and  those  of  Sprengel 
having  given  no  satisfactory  solution  of  this  problem,  we  are  obliged 
to  confess  that  the  etymology  of  the  cesarean  operation  is  no  better 
known  than  its  origin. 

1137.  Rousset  was  the  first  author  who  dared  to  maintain  that  it 
may  and  ought  to  be  had  recourse  to  in  the  living  subject ;  after 
having  cited  various  experiments  and  numerous  analogies,  he  men- 
tions seven  women  who  had  been  subjected  to  the  cesarean  operation 
with  complete  success  ;  but  can  we  rely  upon  the  authenticity  of  the 
case  of  the  woman  named  Godon,  who  was  operated  upon  seven 
times  ;  upon  that  spoken  of  by  the  surgeons  Lenoir  and  Lebrun,  who 


508  CESAREAN  OPERATION. 

operated  upon  the  same  subject  three  times ;  the  recital  of  Alibax, 
of  Sens,  of  Colot,  or  the  story  of  the  woman  who  had  a  long  scar 
upon  the  right  side  of  the  belly,  and  who  said  she  had  a  child  ex- 
tracted through  the  part  seven  years  before  ?  Ought  we  to  receive, 
according  to  the  very  letter,  what  G.  Bauhin  says  of  the  person ' 
called  Alipaschie  of  Siergershensen  in  Germany,  who  was  operated 
upon  by  J.  Nufer,  a  spayer  of  cattle,  after  she  was  given  over  by 
several  midwives,  and  who  recovered  so  happily,  that  several  years 
afterwards  she  was  delivered,  without  danger,  of  two  other  children? 
What  are  we  to  think  of  the  other  fact  mentioned  by  Pare  and 
Schenk  relative  to  Nicola  Berenger  ?  How  happened  it  that  this 
wx)man  was  delivered  two  years  afterwards  of  a  girl,  and  subsequent- 
ly of  a  boy,  if  there  was  any  necessity  for  her  to  undergo  the  cesa- 
rean operation  ?  The  same  may  be  said  of  the  case  of  EHzabeth 
Turgois,  who  subsequently  gave  birth  to  four  children,  by  the  na- 
tural passages,  according  to  the  report  of  the  same  Bauhin.  Lastly, 
it  is  certain  that  of  the  sixty-odd  cases  related  by  Rousset,  Bauhin, 
and  Simon,  only  a  very  small  number  are  quite  conclusive,  and  that 
Pare,  Guillemeau,  Marchant,  Mauriceau,  and  all  persons  who  were 
unwilling  to  be  convinced  except  by  well  established  facts,  were  pos- 
sessed of  excellent  reasons  for  combating  the  assertions  of  Rousset. 

1138.  Be  this  as  it  may,  according  to  Baudelocque  himself,  the 
cesarean  operation  has  been  successfully  performed  twenty-four  times 
from  1760  up  to  the  commencement  of  the  present  century,  and 
without  counting  the  two  cases  of  Lauverjat,  which  are  unquestion- 
able, it  h&s  been  since  performed  at  Nantes  twice  upon  the  same 
woman,  by  Bacqua,  once  by  M.  Lemaistre  of  Aix,  once  by  M. 
Dariste  at  Martinique,  once  by  Vonderfuhr,  in  1823,  at  Dahlen,  once 
by  the  physicians  of  the  hospital  of  Florence,  on  the  18th  of  May 
1827,  twice  by  Schenck,  once  by  Bulk,  once  by  Groefe,  once  by 
Leuch,  once  by  Buren,  another  time,  recently,  in  one  of  the  colo- 
nies ;  so  that  we  cannot  refuse  to  believe  that  at  least  some  women 
may  possibly  be  saved  by  means  of  the  cesarean  operation. 

1139.  The  danger  attending  it  cannot,  however,  be  denied. 
Boerhaave  and  Boer  were  doubtless  wrong  in  stating,  that  scarcely 
one  successful  case  could  be  found  in  fourteen  operations ;  but  it 
is  at  least  certain  that  it  has  been  performed  four  times  within 
the  last  twenty  years  at  the  Paris  Maternite,  and  that  the  wo- 
men all  perished  ;  that  out  of  seventy-three  cases  cited  by  Baude- 
locque, forty-two  were  followed  by  death  ;  that  of  one  hundred  and 
six  cases  reported  by  Sprengel,  forty-five  were  unsuccessful,  and 
that  of  the  two  hundred  and  thirty-one  operations  mentioned  by 
Kelly  and  Hull,  one  hundred  and  twenty-three  were  incompetent  to 


CESAREAN  OPERATION.  509 

save  the  lives  of  the  women  ;  let  us  add  that  all  the  successful  cases' 
have  certainly  been  published,  and  that  there  is  a  great  number  of 
them  whose  authenticity  may  justly  be  called  in  question  ;  whereas, 
according  to  all  appearances,  the  same  thing  has  not  happened  as  to 
the  unsuccessful  cases,  of  which  perhaps  the  greater  proportion 
may  have  been  passed  over  in  silence.  It  may  be  stated,  there- 
fore, that,  up  to  the  present  day,  the  cesarean  operation  has  proved 
fatal  in  at  least  one  out  of  two  cases,  and  that  Tenin  was  mistaken 
in  asserting  that,  since  the  time  of  Bauhin,  it  has  been  performed  at 
the  Hotel  Dieu  on  seventy  women,  who  recovered.  By  the  report 
of  J.  Burns  and  S.  Cooper  it  appears  that  not  a  single  well  at- 
tested case  of  its  successful  performance  has  occurred  in  Great 
Britain,  although  the  number  of  operations  amounts  to  fifteen  or 
twenty. 

I  think  these  details  will  suffice  to  exhibit  this  operation  to  young 
practitioners  in  all  its  importance,  and  to  prevent  them  from  resort- 
ing to  it  in  any  case  save  where  the  necessity  is  absolute. 

Nevertheless,  it  is  difficult  to  conceive  a  priori  that  it  is  of  so 
redoubtable  a  character.  The  wound  which  it  is  necessary  to  make 
in  the  abdomen  is  indeed  very  large,  but  the  parts  divided  are  not 
very  delicate  ;  there  are  no  arteries,  no  large  nerves,  and  nothing 
of  any  great  importance  to  guard  against ;  the  peritoneum  is 
wounded,  but  the  digestive  organs  may  be  easily  avoided  ;  besides, 
how  often  havg  the  largest  and  most  complicated  eventrations,  and 
penetrating  wounds  of  all  kinds  been  seen  which  yet  gave  rise  to 
no  very  serious  consequences,  and  admitted  of  the  recovery  of  the 
patients  ;  is  not  the  serous  membrane  of  the  belly  laid  open  every 
day,  without  our  being  alarmed  about  it,  in  subjects  affected  with 
strangulated  hernia  ?  Would  the  wound  of  the  uterus  alone  prove 
dangerous  ?  but  every  thing  in  this  organ  indicates  that  it  possesses 
but  a  slight  degree  of  irritability,  a  slight  tendency  to  take  on  inflam- 
matory action,  and  has  the  most  favourable  conditions  for  a  sure  and 
prompt  cicatrization.  Are  there  not  several  cases  of  women  who 
underwent  the  cesarean  operation  successfully,  subsequent  to  rupture 
of  the  womb,  and  particularly  the  one'  recently  made  public  by 
doctor  Frank  ?  The  wound,  which  is  at  first  very  large,  is  soon 
reduced  to  one-fifth  or  one-sixth  of  its  original  size,  and  when  the 
organ  is  free  to  contract,  the  hemorrhage  ceases  too  quickly  for  any 
alarm  to  be  felt  in  relation  to  it.  Lastly,  is  it  not  possible  by  pro- 
per precautions  to  prevent  the  liquor  of  the  amnios,  the  blood,  and 
other  fluids  from  being  poured  out  into  the  peritoneum  during  and 
immediately  after  the  operation  ? 

1140.  It  would  seem  then  that  it  is  not  so  much  upon  itself,  as 


510  CESAREAN  OPERATION. 

upon  the  peculiar  state  of  the  woman  at  the  time,  that  the  serious 
nature  of  the  cesarean  operation  depends.  Consequently,  I  can 
scarcely  refuse  to  admit  the  idea,  that  if  we  were  to  act  as  soon  as 
the  indication  becomes  positive,  without  waiting  until  the  person 
becomes  exhausted  with  vain  efforts,  the  uterus  in  a  state  of  inertia 
or  on  the  point  of  becoming  inflamed,  if  not  already  so  ;  until  peri- 
{onitis  or  enteritis  has  became  imminent,  or  existent;  or  lastly,  until 
the  patient's  life  is  in  danger — the  cesarean  operation  would  not  be 
near  so  often  fatal,  as,  unfortunately,  it  has  hitherto  been  found  to  be. 
In  support  of  this  view  of  the  subject,  I  hope  I  may  be  permitted 
to  allege  a  sentiment  of  Dr  Hull,  who  attributes  the  unfortunate 
results  obtained  by  his  countrymen  to  the  circumstance  that  they 
never  operate,  in  England,  except  in  desperate  cases,  whereas  upon 
the  continent  they  are  willing  to  have  recourse  to  it  at  an  early 
period. 

1141.  When  the  smallest  diameter  of  the  pelvis  is  less  than  fif- 
teen lines,  be  the  foetus  dead  or  alive,  the  operation  of  hysterotomy 
is  the  only  chance  of  safety  that  we  can  propose  to  the  woman. 
When  this  diameter  amounts  to  from  eighteen  lines  to  two  inches  and 
a  quarter,  it  is  equally  indispensable,  where  we  do  not  wish  to  act 
upon  the  child ;  but  in  this  case,  the  child  must  be  alive,  and  further, 
it  remains  for  us  to  decide  whether  it  is  better  to  follow  the  English 
doctrine  and  destroy  the  foetus,  than  to  expose  the  mother  to  the 
danger  of  losing  her  life.  Lastly,  it  may  happen  that  we  shall  be 
compelled  to  resort  to  it,  even  although  there  should  be  two  inches 
and  a  half  or  two  inches  and  three-quarters  at  the  smallest  passage, 
provided  the  forceps,  turning,  or  the  section  of  the  pubis  shall  have 
been  deemed  useless,  or  have  been  tried  in  fain. 

1142.  Not  only  ought  the  cerarean  operation  to  be  performed 
upon  the  living  subject,  but  it  is  also  a  rule  of  practice  to  subject  those 
to  it  who  perish  after  the  seventh  month  of  pregnancy  without  being 
delivered. 

The  child  does  not  always  cease  to  live  at  the  same  moment  with 
its  mother,  although  most  frequently  it  dies  first.  We  might  even 
believe,  admitting  as  true  what  has  been  written  upon  the  subject, 
that  life  may  be  maintained  in  the  ovum  more  than  twelve,  twenty- 
four,  or  even  forty-eight  hours.  The  princess  of  Schwartzenberg, 
who  died  at  Paris  in  consequence  of  a  burn,  could  not  be  opened 
until  the  next  day,  and  the  foetus  was,  notwithstanding,  found  to  be 
living.  Another  woman,  mentioned  by  M.  Gardien,  was  not  ope- 
rated on  until  aAer  forty-eight  hours  had  elapsed,  and  the  child 
was  found  to  be  still  alive.  Flajani,  Veslingius  and  several  other 
authors  relate  cases  of  a  similar  character ;  but  may  we  give  credit 


CESAREAN  OPERATION.  511 

to  the  assertions  of  Cangiamila,  when  we  find  him  affirming  in  his 
Sacred  Embryology  that  in  the  space  of  twenty-four  years,  twenty- 
one  children  were  saved  in  this  manner  at  Montereali,  thirteen  at 
Girgenti,  and  that  the  cesarean  operation  was  performed  under  these 
circumstances  twenty  times  at  Syracuse  in  the  course  of  eighteen 
months. 

1143.  Be  this  as  it  may,  the  Roman  law,  lexregia*,  which  is 
referred  to  Numa  Pompilius,  ordered  the  physicians  of  that  period 
to  open  the  bodies  of  all  women  who  died  pregnant,  with  the  view 
of  preserving  citizens  for  the  state.  To  fortify  this  ancient  usage, 
without  compromitting  the  lives  of  women  who  might  be  only  in  a 
state  of  apparent  death,  the  senate  of  Venice  issued  a  decree  in 
1608  and  1721,  which  ordered  severe  penalties  upon  those  members 
of  the  profession  who  should  operate  upon  a  person  supposed  to  be 
dead  without  the  same  degree  of  care  as  if  she  were  actually  living. 
In  1749,  the  king  of  Sicily  made  another  law,  by  which  he  inflicted 
the  penalty  of  death  upon  physicians  who  should  omit  to  perform 
the  cesarean  operation  upon  women  who  should  have  died  in  the 
last  months  of  pregnancy. 

It  is  very  useless,  no  doubt,  to  think  of  preserving  the  life  of  a 
foetus  previously  to  the  end  of  the  eighth  month ;  but  in  Catholic 
countries  there  is  a  desire  at  least  to  baptise  them,  and  tliat  the 
operation  should  be  performed,  in  fact,  if  the  woman  has  passed 
through  one  half  of  the  period  of  pregnancy. 

1144.  As  to  the  necessity  of  acting,  immediately  subsequent  to 
the  death  of  the  mother,  with  the  same  precautions  as  if  the  woman 
Tvere  known  to  be  living,  no  one  will  entertain  a  doubt — in  view  of 
the  difficulty  of  ascerftiining  with  certainty  that  life  is  irrevocably 
extinct,  and  of  the  promptitude  with  which  we  ought  to  act  under 
such  circumstances.  Precipitation  might  really  produce  a  decease 
which  might  possibly  be  otherwise  avoided,  and  the  time  required 
to  establish  the  certainty  of  the  woman's  death  would  more  than 
suffice  to  ensure  the  loss  of  the  child,  which,  in  fact,  is  never  ex- 
tracted alive,  excepting  in  a  few  cases,  appertaining  somewhat  to. 
the  miraculous,  unless  the  extraction  be  effected  during  the  first 
moments  that  succeed  the  death  of  the  mother. 

Van  Swieten  and  Baudelocque  mention  three  cases  of  women, 
•  supposed  to  be  dead,  on  whom  the  cesarean  operation  was  about  to 
be  performed,  when  they  recovered  from  their  lethargic  state.     Peu 
relates  an  instance  far  more  calculated  to  excite  alarm :  he  com- 
menced his  incision,  when  the  woman  gave  a  shudder,  accompanied 

♦  Digest.  lib.  IX,  tit.  viii,  L,  2,  et  lib.  I.  (it.  v.  &c. 


512  CESAREAN  OPERATION, 

with  grinding  of  the  teeth  and  a  movement  of  the  lips.  Rigaudeaux 
has  related  another  one  not  less  remarkable  :  he  was  sent  for,  two 
leagues  from  Douai,  to  see  a  woman  whose  labour  had  excited  great 
uneasiness  ;  when  he  arrived  she  was  believed  to  have  been  dead  for 
two  hours.  Instead  of  opening  the  abdomen  without  any  examina- 
tion, he  explored  the  genital  organs,  found  the  pelvis  well  formed, 
and  proceeded  to  turn  and  deliver  the  child  by  the  feet,  which  was 
born  in  a  state  of  apparent  death,  but  which  with  great  exertion  was 
brought  to  life  in  about  two  hours.  The  limbs  of  the  mother  pre- 
serving their  suppleness,  he  forbid  them  to  bury  her  until  the  abdo- 
men should  have  turned  green  ;  after  a  few  hours  this  woman  reco- 
vered so  completely  from  her  insensibility,  that  sire  came  herself,  four 
years  afterwards,  to  inform  Rigaudeaux  that  she  was  not  dead ! 

Thus,  when  called  to  a  woman  who  has  lately  expired,  the  first 
thing  to  be  done  is  to  ascertain  the  state  of  the  pelvic  passages,  and 
whenever  they  are  sufficiently  capacious,  an  attempt  should  be  made  to 
extract  the  child  through  the  natural  passages.  In  the  second  place, 
if  hysterotomy  is  found  to  be  indispensable,  it  is  to  be  performed 
according  to  the  same  rules,  and  with  as  great  care  as  if  the  woman 
were  living.  By  acting  in  this  manner,  whatever  may  chance  to 
occur,  we  have  nothing  to  reproach  ourselves  with,  and  nobody  is 
liable  to  be  blamed. 

1146.  When  the  cesarean  operation  used  to  be  performed  only 
upon  the  dead  subject,  the  incision  was  made  upon  the  left  side  of 
the  abdomen  ;  "  let  the  woman  be  opened  with  a  razor  along  the  left 
side,^'  says  Guy  de  Chauliac,  "  inasmuch  as  that  part  is  freer  on 
account  of  the  liver."  But  since  it  has  been  attempted  upon  the 
living  female,  it  has  been  subjected  to  rules  formed  on  a- better  foun- 
dation. Among  the  various  methods  proposed  by  different  accou- 
cheurs, there  are  five  which  have  attracted  special  attention  :  in  one 
the  incision  is  made  upon  the  median  line,  and  parallel  to  the  axis 
of  tiic  body ;  in  the  second,  the  cut  is  made  outside  of  the  rectus 
muscle ;  in  the  third,  the  abdominal  parietes  are  divided  transversely, 
upon  one  of  the  sides  ;  in  the  fourth,  the  wound  is  made  immediately 
above  the  Fallopian  ligament  and  parallel  to  that  fibrous  band  ;  and 
lastly,  the  fifth  is  made  at  the  level  of  the  crista  of  the  ilium. 

114C.  Mauriceau^v  method.  Solayrcs,  Henkel,  Deleurye,  &c. 
are  wrong  in  attributing  the  idea  of  cutting  down  upon  the  median 
line  to  Platner,  to  Guerin,  or  to  Varocjuier.  Mauriceau  had  ex- 
pressed himself  in  the  following  terms :  "  Most  persons  direct  the 
incision  to  bo  made  on  the  left  side  of  the  belly,  but  the  opening 
will  be  better  in  the  middle,  between  the  recti  muscles,  for  in  that 
part  there  is  nothing  but  tlio  integuments  and  muscles  to  be  cut." 


CESAREAN  OPERATION.  513 

This  proceeding,  which  is  preferred  by  Baudelocque,  and  now  gene- 
rally followed  in  France,  England  and  Germany,  permits  us  to  avoid 
the  muscles,  and  to  act  only  upon  the  linea  alba;  only  a  slight  de-, 
gree  of  pain  is  produced ;  no  ai'tery  can  be  wounded,  and  moreover, 
the  uterus  is  incised  parallel  to  its  principal  fibres.  But  it  has  also 
been  said  that  this  method  exposes  us  to  the  hazard  of  inflicting  a 
wound  upon  the  bladder,  and  that  the  discharge  of  the  fluids,  whether 
during  or  after  the  operation,  cannot  be  effected  without  difficulty ; 
the  wound  occupying  none  but  fibrous  tissues,  is  slow  in  healing,  and 
the  uterus  being  laid  open  throughout  almost  the  whole  extent  of  its 
anterior  wall,  instead  of  tending  to  approximate  the  lips  of  the  divi- 
sion, rather  separates  them  by  its  contraction. 

1147.  Method  of  .the  ancients.  In  operating  upon  the  side  of 
the  abdomen,  the  ancient  accoucheurs  generally  chose  the  left, 
side,  and  made  sometimes  a  straight,  sometimes  a  slightly  oblique 
incision,  or  one  of  a  crescent  shape,  but  always  immediately  out- 
side of  the  rectus  muscle.  According  to  the  statements  of  the  phy- 
sicians who  employed  it,  this  method  has  over  the  preceeding  one 
the  advantage  of  avoiding  all  danger  of  wounding  the  bladder,  of 
permitting  the  cicatrization  to  be  easily  effected,  and  of  rendering  the 
issue  of  matters  that  must  escape  from  the  wound  far  more  easy. 
As  the  womb  almost  always  undergoes  a  twist  upon  its  axis,  inclin- 
ing to  the  right  or  left,  it  has  been  supposed  that  by  making  the  in- 
cision along  the  median  line,  it  would  fall  nearer  to  its  left  edge  than 
to  the  middle  of  its  anterior  region  ;  this  also  is  one  of  the  consi- 
derations from  which  it  has  been  recommended  that  the  operation 
should  be  performed  upon  the  side  towards  which  the  uterus  has 
naturally  deviated.  Even  admitting  all  these  advantages  to  be  real, 
they  would,  nevertheless,  be  compensated,  it  seems  to  me,  by  the 
risk  of  wounding  the  epigastric  artery  or  some  of  its  branches  ;  of 
having  a  wound,  the  lips  of  which  it  would  be  almost  impossible  to 
keep  in  contact,  on  account  of  the  retraction  of  the  oblique  and 
transversalis  muscles,  and  by  the  impossibihty  of  obviating  the 
absence  of  parallelism  in  the  two  wounds  of  the  abdomen  and  womb. 

1148.  Method  of  Lauverjat.  To  avoid  the  disadvantages  con- 
nected with  these  two  methods,  Lauverjat,  who  had  at  first  admitted 
the  great  superiority  of  hysterotomy  at  the  median  line,  attempted 
to  methodize  a  procedure  which  had  already  been  resorted  to  by 
some  practitioners,  and  recommended  a  transverse  incision  about 
five  inches  in  length,  between  the  rectus  muscle  and  the  spinal  co- 
lumn, somewhat  below  the  level  of  the  third  false  rib,  and  more  or 
less  so  according  as  th<^undus  of  the  womb  is  more  or  less  remote 
from  it.     By  proceeding  in  this  manner  the  fibres  of  the  transverse 

3P 


514  CESAREAN  OPERATION. 

rauscle  are  rather  parted  than  divided  ;  the  epigastric  and  lumbar 
arteries  are  avoided  ;  we  fall  upon  the  fundus  of  the  womb,  whose 
,  cavity  forms  a  sort  of  funnel,  whicii  renders  the  discharge  of  the 
lochia  very  easy,  both  by  the  vagina  and  hypogastrium  ;  the  parallel- 
ism is  easily  maintained  ;  the  suture  is  not  required  ;  mere  position 
suffices  to  keep  the  wound  in  exact  apposition  ;  lastly,  the  external 
angle  of  the  cut  occupying  a  low  situation,  extravasations  into  the 
abdomen  are  incomparably  less  to  be  dreaded  than  in  the  other 
methods.  But  it  may  be  objected  that  the  fibres  of  the  external  and 
internal  oblique  muscles  are  necessarily  divided  ;  that  the  least  ef- 
fort must  force  the  viscera  out ;  that  the  womb  being  divided  at  its 
fundus,  where  its  vessels  are  largest,  soon  removes  to  a  considerable 
distance  from  the  external  opening,  and  that  its  fibres,  by  contract- 
ing, must  rather  hinder.than  promote  the  approximation  of  the  edges 
of  the  inner  incision  ;  so  that,  notwithstanding  the  two  successful 
cases  of  Lauverjat,  and  the  preference  apparently  given  to  him  by 
Sabatier  and  M.  Gardien,  this  method  is  evidently  scarcely  less 
dangerous  than  the  two  former  ones. 

1149.  3IetIiod  of  M.  Ritgen.  Dreading  above  all  things  the 
wounding  of  the  peritoneum  and  of  the  body  of  the  uterus,  Ritgen 
has  of  late  recommended  that  the  attachment  of  the  broad  muscles 
of  the  abdomen  should  be  divided  above  the  crista  of  the  ilium ;  that 
the  peritoneum  should  be  detached  as  far  as  the  superior  strait;  and 
that  the  neck  of  the  womb  should  be  divided  to  a  sufficient  extent 
to  admit  of  the  extraction  of  the  child.  In  the  first  place,  I  cannot 
perceive  how  it  would  be  possible  to  incise  the  apex  of  the  womb 
without  cutting  the  serous  membrane  with  which  it  is  enveloped  ; 
then,  the  difficulties  inherent  in  this  proceeding,  added  to  the  de- 
tachment, which  would  be  produced  in  the  iliac  fossa,  do  not  appear 
to  me  to  be  of  a  nature  to  render  the  operation  at  all  less  serious 
than  those  which  have  been  mentioned  ;  besides,  as  far  as  I  know, 
at  least,  the  operation  is  as  yet  only  a  project,  and  no  one  has  put 
it  in  practice  in  the  living  woman. 

1 150.  Method  of  M.  Baudelocque^  Jun.  Attributing  the  princi- 
pal dangers  of  the  cesarean  operation  to  the  double  wound  of  the 
peritoneum;  and  further,  regarding  wounds  of  the  uterus  as  almost 
essentially  mortal  in  their  character,  M.  Baudelocque  has  proposed 

%  new  method,  which  in  both  these  respects  appears  to  him  to  be 
infinitely  preferable  to  all  others,  and  which  in  fact  differs  from  them 
very  considerably. 

The  incision  is  commenced  near  the  spin©  of  the  pubis,  and  ex- 
tnrwls,  parallel  to  the  Poupart's  ligament,  beyond  the  antero-superior 
spuic  of  the  ilium.     He  selects  the  lefl  side,  on  account  of  the  in- 


CESAREAN  OPERATION.  51 5 

clination  of  the  cervix,  when  the  womb  is  oblique  to  the  right,  and 
the  right  side  where  there  is  a  left  lateral  obliquity.  After  having 
divided  the  abdominal  parietes  without  touching  the  epigastric 
artery,  he  pushes  away  the  peritoneum  from  the  iliac  fossa,  quite 
down  into  the  excavation,  and  detaches  it  from  the  upper  part  of 
the  vagina,  which  he  opens  ;  through  this  opening,  which  ought  to 
be  sufficiently  free,  the  finger  is  conducted  into  the  os  uteri,  which 
is  now  to  be  drawn  up  towards  the  wound  in  the  abdomen,  while 
the  fundus  is  at  the  same  time  pressed  in  an  opposite  direction,  so 
as  to  make  it  turn  over  more  readily.  When  the  operator  has  suc- 
ceeded in  bringing  the  orifice  of  the  womb  cqjposite  to  the  opening 
made  in  the  abdominal  parietes,  the  delivery  is  entrusted  to  the 
uterine  contractions,  or  provided  it  should  be  absolutely  necessary, 
the  orifice  might  be  dilated  with  the  fingers,  and  the  fcetus  extracted 
either  with  the  hand  or  the  forceps. 

1151,  The  idea  of  this  method,  which,  the  author  denominates 
elytrotomy,  is  certainly  ingenious ;  he  has  performed  on  the  dead 
subject,  both  pregnant  and  not  pregnant,  a  number  of  experiments, 
which  have  confirmed  him  in  the  favourable  opinion  he  had  previ- 
ously formed  concerning  if,  and  which  have  sufficed  to  induce  some 
practitioners  to  suspend  their  judgment  in  relation  to  its  value. 
Nevertheless,  I  can  scarcely  believe  that  it  will  be  found  practicable 
in  a  majority  of  cases,  or  that  the  laceration  of  the  vagina,  in  addi- 
tion to  the  disturbance  necessarily  occasioned  in  the  iliac  fossa  or  in 
the  excavation,  would  be  less  redoubtable  than  the  simple  and  metho- 
dical incision  of  the  peritoneum  and  womb,  such  as  may  be  per- 
formed in  ordinary  hysterotomy.  I  may  further  add,  that  M.  Bau- 
delocque  himself  has  very  recently  been  obliged  to  have  recourse  to 
the  cesarean  operation,  properly  so  called,  after  having  tried  the 
operation  of  elytrotomy  in  the  case  of  a  woman  who  had  long  been 
under  his  supervision,  and  in  which  he  was  assisted  by  M.  Hervez 
de  Chegoin.  I  am  aware  that  one  single  fact  does  not  warrant  us 
in  drawing  rigid  conclusions  ;  but  this,  which  is  the  only  one  we 
have  in  regard  to  the  living  subject,  seems  to  me  to  lend  great  ferce 
to  the  distrust  of  the  author's  notions,  derived,  a  priori,  from  reason- 
ing. 

1152.  Method  of  Dr  Physick.  Another  mode  of  operating, 
which  is  somewhat  like  that  of  Professor  Ritgen,  and  also  is  not 
very  different  from  that  of  M.  Baudelocque,  appears  to  have  been 
proposed,  almost  at  tlie  same  time,  by  Dr  Physick.  After  having 
remarked  that,  in  pregnant  women,  the  peritoneum  is  easy  to  sepa- 
rate from  the  bladder  and  parts  about  the  os  uteri,  this  surgeon  con» 
ceived  that  by  making  a  horizontal  incision  immediately  above  the 


516  CESAREAN  OPERATION. 

pubis,  the  os  uteri  might  be  reached  and  opened  without  interesting 
the  peritoneum  :  but  notwithstanding  what  Dr  Horner  may  say 
concerning  it,  this  operation  is  but  little  worthy  of  its  inventor,  and 
does  not  deserve  the  trouble  of  being  discussed. 

1163.  Previously  to  commencing  the  operation,  it  is  proper  to 
soothe  the  mind  of  the  patient  by  inspiring  her  with  the  greatest 
possible  confidence  ;  a  good  condition  of  the  general  strength,  and 
of  the  womb  in  particular;  an  obtuse,  rather  than  a  lively  sensibility; 
a  great  degree  of  resignation,  such  as  are  pretty  often  observed  in 
country-people,  is  most  of  all  to  be  desired  :  if  the  child  is  incur- 
ring any  risks,  we  should  make  haste  ;  otherwise,  bleeding,  baths, 
purgatives  or  any  other"  proper  means  may  be  sometimes  made  use 
of;  and  lastly,  the  conduct  here  in  relation  to  the  preparations,  is 
the  same  as  in  all  the  great  operations. 

If  the  bag  of  waters  is  not  ruptured,  ought  it  to  be  torn,  as  Plan- 
chon  advises,  previously  to  making  the  incision  into  the  womb,  or 
must  it  be  let  alone,  as  most  other  authors  advise?  By  empty- 
ing the  membranes  the  escape  of  the  liquor  amnii  into  the  perito- 
neum is  prevented,  and  there  is  less  reason  for  fear  as  regards  hem- 
orrhage and  inertia  of  the  womb.  But  these  are  not  the  most  to 
be  dreaded  of  all  the  occurrences  that  may  take  place  during  the 
operation  ;  we  are  much  more  frequently  embarrassed  by  the  con- 
traction of  the  womb  than  by  its  inertia.  When  the  ovum  is  whole, 
the  child  can  be  much  more  easily  extracted  ;  the  wound  in  the 
uterus,  at  first  more  extensive,  is  however  reduced  at  last  to  much 
smaller  dimensions ;  lastly,  there  is  less  irritation  excited  in  the 
womb,  and  upon  a  careful  consideration  of  all  the  circumstances,  I 
believe,  in  common  with  M.  Desormeaux,  that  it  is  better  to  preserve 
the  membranes  whole. 

We  should  never  omit  to  empty  the  rectum  and  bladder,  especially 
if  it  be  intended  to  follow  the  method  of  Mauriceau.  The  appa- 
ratus consists  of  a  convex  bistoury,  a  straight  probe-pointed  bistoury, 
pincers,  scissors,  suture  needles,  thread,  quill-barrels,  adhesive  strips, 
lint  in  rolls  and  in  pledgets,  of  pieces  of  linen  spread  with  cerate,  of 
compresses  both  oblong  and  square,  a  bandage  for  the  body,  small 
and  large  sponges,  a  syringe,  canulas  of  gum-elastic,  to  be  used  in 
case  it  should  be  necessary  to  make  any  injections,  water,  both  cold 
and  warm,  and  vinegar;  wine  and  cologne-water  are  also  necessary. 

If  possible,  the  patient  'Should  be  laid  on  the  bed  that  she  is  to  oc- 
cupy during  the  first  few  days  after  the  operation  ;  her  position 
ought  to  be  an  easy  one.  She  should  be  placed  on  her  back,  witli 
the  logs  nnd  tliigha  very  slightly  bent,  and  assistants  arc  charged  to 
watch  againpt  any  sudden  movements  which  the  pain  might  compel 


CESAREAN  OPERATION.  517 

her  to  execute  ;  two  intelligent  assistants  must  apply  their  hands 
upon  the  sides  and  fundus  of  the  womb,  so  as  to  circumscribe  it 
very  exactly,  in  order  that  no  organ  may  happen  to  slip  betwixt  its 
surface  and  the  abdominal  parietes,  and  so  that  it  may  compose 
with  the  latter  parts  but  one-  single  mass.  For  this  purpose  the 
naked  hands  seem  to  me  less  suitable  than  they  would  be  if  applied 
upon  pieces  of  broad  flat  sponge,  as  advised  by  Dr  Hedenus. 

1154.  With  the  convex  bistoury  the  surgeon  makes  an  incision 
through  the  integuments,  from  near  the  umbilicus  towards  the  pubis, 
in  length  from  five  to  six  inches,  without  its  being  necessary,  or  al- 
ways even  possible,  to  pinch  up  a  large  fold  of  them,  as  advised  by 
Levret.  The  sub-cutaneous  layer,  the  aponeurosis  and  the  muscu- 
lar fibres,  as  well  as  the  cellular  tissue,  provided  we  do  not  operate 
upon  the  median  line,  are  successively  divided  in  the  same  manner 
and  to  'the  same  extent.  This  incision  ought  not  to  be  carried  too 
near  to  the  pubis,  on  account  of  the  bladder,  and  because  the  ab- 
dominal parietes  are  generally  very  thick  in  that  situation.  It 
would  be  better  to  extend  it  above  the  umbilicus,  taking  care  to  pass 
to  the  left  of  it,  so  as  to  avoid  the  umbilical  vein,  and  more  parti- 
cularly, the  anastomosis  which  may  exist  between  it  and  the  epigas- 
tric vein,  an  anastomosis  which  has  latterly  been  noticed  by  M. 
Mesniere,  Clement,  and  Martin. 

After  having  opened  the  peritoneum  so  as  to  admit  of  the  intro- 
duction of  the  left  fore  finger,  to  serve  as  a  conductor  for  the  in- 
strument, the  wound  in  that  membrane  is  to  be  enlarged  by  means 
of  the  probe-pointed  bistoury,  to  the  same  extent  as  the  wound  in 
the  skin. 

The  womb  is  now  exposed ;  it  is  to  be  incised  layer  by  layer,  and 
slowly,  until  we  reach  the  surface  of  the  ovum  ;  then,  in  order  to 
retain  for  the  cervix  as  much  of  its  length  as  possible,  the  assistants 
are  told  gently  to  press  the  fjundus  of  the  uterus  downwards  and 
make  it  turn  somewhat  in  front ;  we  might,  indeed,  like  Dr  Kluge, 
hook  the  lower  angle  of  the  wound  of  that  organ  with  the  finger,  so 
as  to  favour  such  a  movement,  which  by  affording  a  facility  for  ex- 
tending the  section  very  far  upwards,  permits  us  to  guard  the  cer- 
vix. In  order  to  avoid  the  risk  of  wounding  the  vessels  of  the 
placenta,  it  is  better  to  use  the  prcbe-pointed  bistoury  to  finish  the 
incision,  than  to  have  recourse  to  the  grooved  director  to  guide  the 
bistoury  with.  Further,  I  can  conceive  no  objection  to  letting  the 
point  of  the  finger  detach  the  placenta  and  membranes  to  a  certain 
extent. 

This  is  the  moment,  and  not  before  the  commencement  of  the 
operation,  that  it  would  be  perhaps  well  to  follow  the  advice  of  Plan- 
chon,  and  rupture  the  membranes  by  passing  the  finger  up  the 


518  CESAREAN  OPERATION. 

vagina,  either  with  the  fingers  alone,  or  with  the  instrument  of  Sie- 
bold,  as  is  generally  done  in  Germany ;  supposing,  which  appears 
to  me  preferable,  that  the  membranes  should  be  pierced  from  the 
incision,  it  will  be  necessary  for  the  assistants  to  redouble  their  care 
to  prevent  the  parietes  of  the  abdomen  from  abandoning  the  wombj 
in  this  way  the  effusion  of  the  waters  into  the  cavity  of  the  perito- 
neum will  be  obviated,  and  the  tendency  of  the  viscera  to  escape 
outwards  will  remain  ineffectual.  > 

1156.  The  extraction  of  the  child  ought  to  take  place  without 
delay  ;  when  it  presents  by  the  head  or  by  the  breech  it  is  drawn 
away  in  that  position,  and  to  favour  its  escape,  the  assistants  are 
told  to  press  gently  upon  the  sides  of  the  womb  through  the  parietea 
of  the  abdomen  ;  if  it  be  situated  otherwise,  the  feet  must  be  got 
hold  of,  and  the  extraction  performed  with  the  same  precautions  as 
in  delivery  by  the  natural  passages,  special  care  being  taken  not  16 
bruise  or  stretch  the  lips  of  the  wound  in  the  uterus. 

11166.  As  soon  as  the  foetus  is  withdrawn,  the  practice  recom- 
mended by  Planchon  might  be  adopted,  viz.  by  means  of  a  sound, 
the  cord  might  be  repassed  through  the  wound,  for  the  purpose  of 
removing  the  after-birth  through  the  vagina,  but  no  beneficial  effects 
would  be  ultimately  obtained  by  it,  and  the  celerity  of  the  operation 
would  be  sensibly  lessened;  after  all,  the  retraction  of  the  womb, 
which  would  most  generally  render  this  operation  impossible,  soon 
forces  the  placenta  to  engage  in  the  wound,  and  thus  points  out  the 
route  we  should  select  in  extracting  it.  In  order  that  it  may  pre- 
sent less  volume  and  less  resistance,  one  of  its  edges  even  may  be 
taken  hold  of,  if  possible,  rather  than  pull  it  away  by  the  cord  only. 
As  to  the  membranes,  they  must  be  carefully  twisted  into  a  rope  as 
in  a  natural  delivery,  to  prevent  any  of  them  from  remaining  in  the 
uterus.  Should  any  blood  have  been  lost  and  formed  into  clots, 
they  ought  to  be  removed  with  the  hand.  It  would  be  well,  more- 
over, to  cleanse  all  the  parts  by  means  of  an  injection  of  warm  wa- 
ter ;  but  I  do  not  think  that  for  the  purpose  of  keeping  the  os 
uteri  open,  it  is  of  any  advantage  to  place  in  it  the  tent  recom- 
mended by  Baudelocque,  nor  the  cierge  pertuisS  of  Ruleau,  nor  the 
tent  of  Rousset,  nor  the  sound  of  M.  Tarbes,  nor  any  species  of 
canula  whatever ;  these  means  would  not  prevent  the  os  uteri  from 
closing,  and  would  augment  the  irritation  to  no  purpose.  The  finger 
introduced  from  time  to  time  suffices  to  keep  it  free  enough,  should  it 
cease  to  give  issue  to  the  matters,  which,  after  all,  nothing  can  pre- 
vent from  passing  wholly  or  partly  out  at  the  wound. 

Wfyl.  The  operation  being  terminated,  we  must  next  think  of 
putting  a  stop  to  the  flow  of  blood.  In  the  lateral  operation,  and 
especially  in  that  of  Lauverjat,  several  arteries  may  liave  been 

s 


CESAREAN  OPERATION.  519 

divided ;  they  should  now  be  tied^  provided  they  should  not  have  been 
secured  during  the  progress  of  the  operation.  During  the  operation, 
the  principal  orifices  of  tiie  uterine  arteries  have  been  closed  by  the 
fingers  of  the  assistants ;  there  never  can  arise  any  question  about 
obliterating  them  with  the  ligature ;  but  it  has  been  recommended 
to  cauterise  them  with  vitriol,  and  generally,  to  trust  them  to  the 
contractions  of  the  womb,  which  is  to  be  solicited,  provided  it  be 
slow  in  taking  place,  by  irritating  the  cavity  of  the  organ  or  the  lips 
of  the  wound  with  the  fingers,  or  linen  moistened  with  vinegar  and 
water ;  after  a  few  minutes  the  length  of  the  incision  in  the  womb  is 
reduced  to  from  one  to  two  inches,  and  th.enceforth  hemorrhage  of 
any  kind  becomes  impossible. 

1168.  In  England,  in  Germany,  and  also  in  France,  the  wound 
in  the  abdomen  is  generally  closed  by  the  interrupted  or  twisted 
suture,  because,  it  is  said,  that  is  the  only  means  of  keeping  the  lips 
in  contact,  and  of  preventing  hernia  of  the  viscera.  Sabatier,  how- 
ever, thinks  it  ought  to  be  dispensed  with,  and  says  that  unless  the 
whole  thickness  of  the  abdominal  parietes  be  included  in  each  stitch, 
which  would  be  dangerous,  the  adhesive  strips  will  do  as  much  as 
the  sutures,  without  compromitting,  in  the  same  manner,  the  safety 
of  the  patient.  But  notwithstanding  the  reasons  urged  by  that 
learned  author,  it  seems  to  me  to  be  proferable  to  have  recourse  to 
the  suture,  even  where  Lauverjat's  operation  has  been  adopted. 
In  all  cases,  the  lower  corner  of  the  wound  should  be  left  free,  to 
allow  the  matter  to  escape.  Besides,  the  sutures  do  not  prevent  the 
application  of  adhesive  strips  over  their  intervals,  nor  the  favourable 
action  of  the  uniting  bandage,  and  a  proper  position. 

The  wound  is  then  covered  with  a  piece  of  linen,  perforated,  or 
with  strips  spread  with  cerate ;  two  long  and  broad  compresses  are 
placed  on  the  sides ;  some  pledgets  of  soft  lint,  common  compresses, 
and  a  body-bandage  well  applied,  will  complete  the  dressing. 

Previously  to  leaving  the  woman,  the  linens  soiled  during  the 
operation  should  be  removed ;  she  is  to  be  placed  in  the  middle  of 
her  bed,  taking  care  to  move  her  as  little  as  possible,  and  we  should 
endeavour  to  place  her  so  that  her  muscles  may  be  all  in  a  state  of 
relaxation.  '     , 

1159.  Some  antispasmodic  potions,  slightly  opiated,  to  calm  the 
nervous  agitation ;  softie  precautions  to  ensure  the  discharge  of  the 
lochia  by  the  vagina  instead  of  their  escaping  into  the  peritoneum  ; 
diluting  drinks,  bleeding  and  leeching  as  soon  as  any  symptoms  of 
inflammatory  action  become  manifest,  and  the  greatest  repose,  both 
of  mind  and  body,  are  all  that  the  surgeon  can  recommend  to  the 
patient  to  obviate  the  dangers  which  threaten  her. 


520  VAGINAL  CESAREAN  OPERATION. 


SECTION  5.  ^.. 

Vaginal- Cesarean  Operation. 

1160.  According  to  the  reports  of  authors,  a  great  number  of 
causes  may  necessitate  the  performance  of  the  vaginal-cesarean 
operation :  an  obliteration  with  fibro-cartilaginous  induration  of  the 
OS  uteri,  as  in  the  case  related  by  Simson,  and  also  in  that  other 
case  spoken  of  by  Van-Swieten ;  violent  convulsions  which  endanger 
the  life  of  the  woman  while  the  orifice  is  too  tense,  and  still  insuffi- 
ciently dilated  to  admit  of  the  introduction  of  the  hand,  as  is  observed 
in  the  cases  by  Dubosq  and  Lambron ;  an  extreme  obliquity  of  the 
orifice  backwards,  while  the  head  of  the  child  at  the  same  time 
forces  down  in  the  excavation,  and  even  as  low  as  the  vulva,  the 
anterior  portion  of  the  womb,  which  it  distends,  renders  thin,  and 
would  at  last  rupture,  provided  an  incision  .were  not  soon  made,  as 
was  done  by  Lauverjat — such  are  the  occurrences  which  have  most 
frequently  rendered  it  necessary ;  it  may  also  become  useful  where 
the  uterus,  having  escaped  from  the  pelvis  during  pregnancy,  has 
never  been  reduced,  and  where  its  orifice  cannot  be  dilated  by 
means  of  the  fingers,  although  there  may  be  danger  in  delaying  the 
delivery,  as  in  the  examples  cited  by  M.  Thenance,  Jacomet,  and  b^ 
surgeon  at  Vaux  mentioned  by  M.  Bodin ;  but  it  has  been  proposed 
more  particularly  in  cases  of  scirrhus,  and  where  the  orifice  presents 
such  a  I'esistance  to  the  contractions  of  the  womb  that  the  woman 
is  exhausted  in  vain  eflbrts  without  effecting  its  dilatation ;  lastly,  it 
would  be  equally  well  indicated,  as  M.  Codin  has  attempted  to  de- 
monstrate, in  cases  of  arm  presentation,  should  it  ever  in  any  case  be 
found  really  impossible  to  proceed  in  search  of  the  feet,  and  if  no 
other  means  of  avoiding  the  amputation  of  the  arm  could  be  availed  of. 

IIGI.  Altiiough  generally  attended  with  but  little  danger,  the 
accoucheur  would  be  blamcable  who  should  perform  it  without  a  well 
ascertained  necessity;  I  cannot  therefore  but  Condemn  in  decided 
terms  the  temerity  of  those  practitioners  who  do  not  hesitate  to 
employ  it,  simply  because  the  os  uterf  happens  to  be  somewhat 
dense,  and  does  not  dilate  according  to  their  impatient  desires  ;  and 
according  to  what  I  said  when  speaking  of  deviations  of  the  os  lUeri^ 
I  have  no  doubt  that  it  has  often  been  performed  when  it  might 
have  been  easily  dispensed  with. 

in  all  cases,  if  there  ia  an  orifice,  nothing  is  easier  than  to  per- 
form this  operation  ;  the  speculum,  employed  by  some  persons  is  of 
no  use ;  a  probc-pointcd  bistoury,  wrapped  round  with  a  narrow 


VAGINAL-CESAREAN  OPERATION.  521 

atrip  of  linen  to  within  eight  or  twelve  lines  of  its  point,  is  passed 
up  upon  the  index  finger  ;  in  this  way  we  carry  it  without  difficulty 
within  the  os  uteri,  provided  it  be  not  too  far  distant  from  the  centre 
of  the  pelvis ;  in  the  contrary  case,  Pott's  curved  bistoury  should  be 
substituted  for  the  straight  one.  Strictly  speaking,  one  incision 
might  be  deemed  sufficient ;  but/as  it  is  important  that  it  should  not 
be  too  deep,  it  would  be  preferable  to  make  several  of  them,  at  a 
small  distance  from  each  other.  At  a  first  view,  it  would  seem  that 
the  passage  of  the  head  could  not  take  place  without  enlarging  such 
wounds  so  as  to  extend  them  to  the  body  of  the  womb,  and  lacerate 
the  peritoneum  ;  but  in  fact  this  does  not  happen,  and  they  com- 
monly remain  limited  to  the  substance  of  the  os  uteri.  In  operating 
for  a  scirrhous  or  fibrous  induration,  but  a  very  few  ounces  of  blood 
are  found  to  flow  from  the  wound.  M.  Duges  is,  in  my  opinion,  right 
in  recommending  that  all  the  diseased  parts  should  be  removed  at 
.once,  instead  of  merely  incising  them. 

1 162.  When  the  anterior  wall  of  the  uterus  is  divided  without 
extending  the  cut  down  to  the  os  uteri,  we  are  obliged  to  make  use 
of  a  straight,  or  convex,  and  not  a  probe-pointed  bistoury,  to  begin  the 
operation  with,  which  is  always  a  more  delicate  one  than  the  pre- 
ceding. Too  much  care  cannot  be  taken  to  avoid  wounding  the  pre- 
senting part  of  the  fcetus  while  making  the  incision.  But,  when 
the  womb  has  been  once  penetrated,  the  forefinger  becomes  a  sure 
director,  and  the  instrument  may  enlarge  the  womb  as  much  as 
necessary,  without  any  danger  ;  let  us  however  observe  that  there 
is  less  hazard  in  extending  the  incision  backwards  than  forwards, 
on  account  of  the  bladder,  and  also,  that  it  is  useless  to  make  it  very 
large.  After  the  delivery,  the  wound  contracts  very  rapidly,  and  it 
often  happens  that  not  a  half  day  elapses  before  the  os  uteri  recovers 
its  natural  situation.  If  the  blood  should  flow  in  too  large  a  quan- 
tity, it  would  be  easily  arrested  by  injections  of  oxicrate,  and  by  the 
tampon  ;  and  the  cautery,  which  is  easy  to  apply,  will  rarely  be 
necessary  in  such  cases.  As  to  the  lochia,  they  escape  either  from 
the  wound  or  from  the  orifice  of  the  uterus,  and  in  these  respects 
the  woman  requires  only  such  cares  as  are  common  after  an  ordinary 
parturition. 

SECTION  6. 
Of  Cephalotomy  and  Embryotomy. 

1 163.  In  England  the  perforation  of  the  cranium  or  reduction  of 
the  foetus,  by  removing  successive  portions  of  it,  even  where  it  is  still 

3Q 


522  CEPHALOTOMY  AND  EMBRYOTOMY. 

known  to  be  living,  is  generally  preferred  to  the  cesarean  operation. 
Wigan,  combatted  by  Busch,  maintains  the  same  sentiment  in  Ger- 
many. In  France  the  operation  of  cephalotomy  is  not  performed 
except  where  the  death  of  the  child  has  been  certainly  ascertained, 
or  at  least  become  very  probable,  and  where  the  delivery  by  the 
natural  passages  is  altogether  impossible.  When  the  pelvis  has  a 
diameter  less  than  fifteen  lines,  or  the  whole  hand  cannot  penetrate 
into  the  womb,  the  cesarean  operation  is  preferred,  even  though  the 
child  be  dead.  Upon  this  subject  I  will  remark  that  our  neighbours 
too  rarely  have  recourse  to  hysterotomy,  and  that  they  are  too  ready 
to  sacrifice  the  child,  for  fear  of  compromising  the  life  of  the  mother ; 
that  here  we  fall  into  an  excess  of  quite  an  opposite  kind,  and 
which  is,  perhaps,  scarcely  less  blameable.  In  a  case  where  every 
circumstance  announces  that  the  fgetus  is  still  in  full  vigour,  and  that 
it  is  robust,  there  is  no  doubt  that,  instead  of  sacrificing  it,  as  is  done 
in  Great  Britain  and  at  the  north,  it  ought  to  be  extracted  without 
endangering  its  life,  by  means  of  operations  which  indeed  are  severe, 
but  not  always  fatal  to  the  woman ;  there  is  also  no  doubt,  in  my 
opinion,  that  cephalotomy  ought  to  be  preferred  when  there  are  good 
reasons  for  fearing  the  child's  death,  or  for  believing  that  it  cannot 
continue  to  live.  It  would  be  too  cruel,  after  performing  the  cesa- 
rean operation,  to  be  able  to  present  only  a  corpse,  or  a  feeble,  mise- 
rable being,  which  must  perish  in  a  few  minutes  or  hours,  to  the 
unhappy  mother  as  the  price  of  all  her  sufferings  and  dangers ! 
But  it  would  be  a  great  mistake  also  to  suppose  that  embryotomy  is 
wholly  unattended  with  danger  to  the  mother  ;  it  is,  on  the  contrary, 
one  of  the  roost  redoubtable  and  revolting  operations  in  tokology, 
whenever  it  extends  beyond  the  mere  operation  of  craniotomy. 

1164.  To  sum  up,  the  operation  of  cephalotomy  is  indicated, 
ii  |.  When  the  fcetus  is  dead  and  the  passages  are  too  much  con- 
tracted to  permit  its  extraction  with  the  forceps  or  by  turning ; 
2.  When  it  is  very  probable  that  the  child  is  dead,  or  at  the  point 
of  death,  and  when  it  cannot  be  got  away  whole  without  the  per- 
formance of  the  operation  of  hysterotomy  ;  3.  When  the  head  alone 
remains  in  the  pelvis  and  cannot  be  extracted  by  the  hand,  the  for* 
ceps,  or  crotchet.  It  would  be  useless,  dangerous,  and  ought  to  be 
proscribed  even  in  case  the  foetus  were  dead,  provided  the  small  dia- 
meter of  the  inferior  strait  were  less  than  eighteen  or  twenty  lines 
in  extent. 

1165.  Embryotomy,  that  is  to  say,  that  operation  which  consists 
in  introducing  a  cutting  instrument  within  the  cavity  of  the  womb, 
for  the  purpose  of  lessening  tho,  size  of  the  child,  dividing,  and  re- 
ducing it  to  small  pieces,  so  as  to  be  afterwards  able  to  extract  it 


CEPHALOTOMY  AND  EMBRYOTOMY.  523 

piece-meal,  was  frequently  employed  by  the  ancients,  who  had  no 
other  resource,  and  did  not  confide  enougli  in  the  powers  of  the  sys- 
tem ;  but  at  the  present  day  the  forceps,  the  lever,  turning,  symphy- 
seotomy, and  the  cesarean  operation,  properly  appreciated  as  to  their 
respective  value,  render  it  almost  wholly  useless  ;  it  is  therefore  no 
longer  performed  at  the  present  day,  except  by  certain  country  me- 
dicasters, who  are  as  ignorant  of  the  art  of  midwifery,  which  they 
disgrace,  as  they  are  of  the  plainest  principles  of  the  other  branches 
of  medicine. 

1166.  Even  the  operation  of  craniotomy  must  very  rarely  be 
necessary  or  indispensable,  since  out  of  a  total  of  more  than  twenty 
thousand  labours  Madame  Lachapelle  has  indicated  only  three  in- 
stances of  it.  In  performing  it,  Avicenna  and  Mauriceau  made 
use  of  sharp  extractors  in  the  shape  of  a  crotchet ;  Levret,  Denys, 
Fried,  and  Ould,  made  use  of  sheathed  perforators ;  Simson  boasted 
of  a  ring-scalpel;  spear-pointed  perforators  have  been  recommended 
and  modified  in  an  infinite  variety  of  ways  ;  but  at  present  a  simple 
bistoury  is  employed,  or  the  scissors  of  De  la  Motte,  improved  by 
Smellie  and  by  Walbaura,  are  made  use  of  when  it  is  necessary  to 
penetrate  to  a  great  depth  within  the  organs,  and  to  exert  a  cer- 
tain degree  of  force  to  perforate  the  bones. 

1 167.  The  woman  should  be  placed  as  for  the  application  of  the 
forceps  ;  the  bistoury,  wrapped  with  a  small  linen  roller  to  within 
a  few  lines  of  its  point,  which  Baudelocque  guarded  with  a  small 
ball  of  wax,  is  directed  along  the  palmar  surface  of  one  or  two 
fingers  of  either  hand,  previously  introduced  into  the  vagina,  and  so 
on  to  the  head  which  is  to  be  opened.  To  insert  the  scalpel,  a  fon- 
tanel, or  at  least  a  suture,  is  to  be  selected,  when  the  vertex  is  the 
presenting  part :  where  the  trunk  of  the  body  is  delivered  we  may 
be  obliged  to  perforate  the  bones  themselves,  in  which  case  we  ad- 
dress the  instrument  to- the  forehead,  or  even  to  the  base  of  the  oc- 
cipital bone.  When  the  head  is  left  in  the  pelvis,  we  ought  also  to 
endeavour  to  find  one  of  the  membranous  spaces ;  but  it  is  not  al- 
ways easy  to  reach  them,  and  the  accoucheur  must  then  choose  the 
bone  which  offers  the  least  resistance,  and  which  his  finger  can 
touch.  During  this  operation,  if  the  head  be  somewhat  movable, 
an  assistant  ought  to  embrace  the  womb  with  both  hands,  as  advised 
by  Celsus,  and  push  it  down  towards  the  strait,  so  as  to  steady,  as 
much  as  possible,  the  parts  about  to  be  divided.  On  the  other  hand, 
the  point  of  the  instrument  ought  never  to  move,  while  within  the 
maternal  organs,  without  being  guarded  by  covering  it  with  the 
point  of  one  of  the  fingers.  When  it  is  once  plunged  into  the 
cranium,  the  incision  is  prolonged  as  far  as  possible,  at  least  to  the 


524  CEPHALOTOMY  AND  EMBRYOTOMY. 

extent  of  an  ineh ;  most  commonly,  we  should  not  be  satisfied  with 
making  only  one  incision  ;  we  ought  to  make  a  cracial  opening, 
through  which  the  finger  may  be  passed  so  as  to  break  up  the  brain, 
which  may  also  be  lacerated  with  the  cephalotome  itself. 

If  Smellie's  perforator  is  selected  for  the  operation,  it  is  to  be  intro- 
duced and  shut  with  the  same  precautions  pointed  out  when  speak- 
ing of  the  use  of  the  bistoury  ;  when  closed  it  resembles  a  common 
cephalotome  ;  but  as  the  two  branches  of  which  it  is  composed  are 
sharp  on  their  outer  edges,  when  they  are  opened,  it  necessarily  en- 
larges the  incision  at  first  made  by  its  introduction,  in  direct  pro- 
portion to  the  degree  of  the  opening ;  it  is  then  shut,  to  be  opened 
again  in  another  direction  ;  after  which  it  may  be  made  use  of  to 
reduce  the  brain  to  the  consistence  of  gruel. 

If  the  disproportion  betwixt  the  child's  head  and  the  pelvis  is  not 
considerable,  and  the  womb  still  retains  its  energy,  the  remainder 
of  the  labour  is  confided  to  the  efibrts  of  the  woman,  and  termi- 
nates with  much  rapidity  ;  in  the  contrary  case,  we  are  obliged  to 
resort  to  the  employment  of  the  forceps,  or  crotchet.  The  forceps 
would  be  always  preferable  where  it  could  be  applied,  and  when  the 
head  is  still  somewhat  firm  ;  and  provided  it  where  not  so  liable  to 
slip  and  lose  its  hold,  upon  the  application  of  some  degree  of  ex- 
tractive force. 


*  SECTION  7. 

Of  Crotchets,  and  their  Use. 

Crotchets  were  formerly  employed  in  almost  all  the  cases  that  are 
now  happily  terminated  by  means  of  the  forceps,  and  in  an  infinity 
of  others,  which,  by  means  of  turning,  or  the  skilful  use  of  the  hand, 
are  capable  of  being  brought  to  a  favourable  conclusion  ;  but  their 
employment  becomes  more  and  more  rare,  as  the  knowledge  of 
obstetrics  extends,  as  well  as  that  of  all  the  other  destructive  in- 
struments which  were  so  much  abused  by  the  ancients. 

1168.  Crotchets  are  of  two  kinds:  one,  terminated  by  a  blunt 
and  rounded  extremity,  or  else  of  an  olive  shape,  and  more  or  less 
bulbous,  which  are  proposed  as  substitutes  for  the  fingers  or  (he 
fillet,  do  not  divide  the  parts  of  the  child,  and  are  applied  either 
while  it  is  living,  or  after  its  death,  upon  diff*erent  parts  of  its  body. 
They  are  constructed  of  various  forms.  It  has  been  recommended 
that  they  should  all  be  replaced  by  the  one  which  terminates  the 
handle  of  the  modern  forceps  ;  but  the  best  ones  consist  of  a  long 
piece  of  steel,  supported  by  a  wooden  handle,  and  curved  into  an 


THE  CROTCHET.  525 

arc  of  a  circle,  the  sinus  of  which  is  sufficiently  open  to  embrace 
without  difficulty  the  groin,  the  ham,  or  the  axilla  ;  when  only  bent 
at  a  right  angle,  as  advised  by  Madame  Lachapelle,  they  slip  too 
readilv  ;  if  bent  into  the  shape  of  the  letter  S,  or  contracted  in  too 
acute  an  angle,  they  will  not  fit  accurately  to  the  part  on  which  they 
may  have  to  be  applied  ;  Baudelocque,  Steidele,  and  most  of  the 
accoucheurs  of  the  present  day,  have  imagined  that  the  two  blunt 
crotchets  of  the  forceps  might  be  united,  so  as  to  form  a  pincers 
with  a  curved  end,  and  to  be  applied  to  both  groins  at  once  ;  but 
it  does  not  appear  that  such  a  modification  can  ever  be  wanted.  A 
single  branch  commonly  suffices,  and,  with  the  exception  of  a  few 
cases,  the  fingers  are  a  very  good  substitute.  The  utility  of  the 
blunt  crotchet,  however,  can  scarcely  be  doubted  when  from 
any  cause  whatever  the  head  has  been  separated  from  the  trunk, 
which  cannot  be  extracted  except  by  acting  upon  the  axilla ;  in  such 
a  case,  as  in  breech  and  knee  positions,  the  only  rule  that  it  is  im- 
portant to  follow  is,  always  to  act  upon  the  bend  of  the  limb  that 
looks  to  the  back  part  of  the  woman's  pelvis,  and  in  drawing  down, 
not  to  lose  sight  of  the  axes  of  the  pelvis. 

1169.  The  point  of  the  sharp  crotchet  is  sometimes  round,  as  in 
the  olive  of  the  forceps,  sometimes  flat  and  triangular,  as  in  Mauri- 
ceau's  and  most  of  the  ancient  instruments,  so  that  the  entire  instru- 
ment is  nothing  more  than  a  cephalotome  with  a  bent  blade. 
This  point,  which  is  single  in  some  and  in  others  double,  may  be 
continuous  with  a  straight  or  with  a  curved  stem,  or  it  may  resem- 
ble a  hook  of  a  chain,  of  greater  or  less  length,  like  what  is  seen  in 
Scultetus's  Armamentarium;  the  point,  which  in  most  of  the  speci- 
mens is  fixed,  may  however  bend,  and  also  open  as  in  the  instruments 
of  Aitken  and  Saxtorph.  Forceps  or  pincers  with  sharp  crotchets 
have  also  been  constructed;  Mesnard,  Levret,  Smellie,  Baudelocque, 
and  many  others  have  boasted  of  the  value  of  the  crotchet-forceps,  a 
model  of  which  is  to  be  seen  in  the  Museum  de  la  Faculty,  and  which 
are  nothing  more  than  SmelHe's  small  forceps  without  fenestres  in  the 
blades,  which  are  terminated  by  a  triangular,  sharp  and  bent  point. 
The  forceps  with  wolf-teeth  of  Avicenna,  and  the  dentated  pincers 
of  Ruefi'  ought  also  to  be  classed  among  the  sharp  crotchets. 

''1 170.  After  the  performance  of  craniotomy,  if  the  powers  of  na- 
ture are  insufficient,  Burns  thinks  that  we  ought  to  wait  twenty-four 
hours  before  we  resort  to  the  triple  forceps  of  Levret,  and  more  es- 
pecially to  the  sharp  crotchet ;  he  founds  this  doctrine  on  the  circum- 
stance, that  the  fcetus,  passing  rapidly  into  a  state  of  putrefaction, 
softens,  and  becomes  much  easier  to  extract  the  longer  we  wait, 
even  admitting  that  it  shall  not  be  spontaneously  expelled. 

This  practice,  although  recommended  by  Kelly,  M'Kenzie,  Den- 


526  THE  CROTCHET. 

man,  Osborn,  Boer,  Simson  and  Asdrubali,  does  not  appear  to  me 
to  be  one  that  ought  to  be  followed  ;  I  agree  with  M.  Duges  that 
it  is  useless  to  protract,  in  this  way,  the  patient's  anguish  ;  and  be- 
sides, a  labour  that  is  already  tedious  cannot  be  with  impunity  pro- 
tracted for  twenty-four  or  forty-eight  hours  longer ;  and  were  there 
no  other  reason  than  the  necessity  for  renewing  the  preparations  for 
a  forced  delivery,  which  are  always  frightful,  it  ought  to  be  rejected. 

1171.  The  sharp  crotchet  is  to  be  applied  to  one  of  the  most 
solid  parts  of  the  cranium,  for  example,  to  the  occiput  or  the 
mastoid  process,  when  the  head  comes  foremost ;  upon  the  lower 
jaw,  in  the  orbit,  or  upon  the  forehead,  when  it  descends  after  the 
trunk  ;  in  short,  in  such  a  way  as  to  prevent,  as  far  as  possible,  the 
occipito-mental  diameter  from  abandoning  the  line  of  the  axes  of 
the  pelvis,  and  to  retain  it  in  its  natural  state  of  flexion.  It  may 
also  be  applied  inside  of  the  cranium,  by  fixing  it  on  the  petrous 
portion  or  the  basilar  apophysis  ;  but  in  that  case  it  is  of  essential 
importance  that  it  shall  not  slip,  that  it  shall  not  act  upon  one  of  the 
bones  of  the  vault  of  the  cranium,  for  by  pulling  them  downwards 
it  might  pass  through  them  and  injure  the  organs  of  the  woman. 
Like  the  perforator,  the  sharp  crotchet  ought  never  to  be  plunged 
into  the  foetus  without  being  guided,  in  some  sort  protected,  or  even 
covered  by  the  accoucheur's  finger  ;  when  fixed  either  on  the  in- 
terior or  exterior  of  the  cranium,  the  stem  must  be  supported  by 
the  thumb,  while  the  fingers  remain  firmly  applied  to  the  opposite 
side  of  the  head,  and  the  other  hand  applied  to  the  handle  exerts 
the  requisite  extractive  power.  In  this  way  it  cannot  let  go  its  hold 
without  the  accoucheur's  perceiving  it  at  once  ;  both  the  hands  also 
act  in  concert,  their  efforts  may  be  exactly  combined,  and  the  oper- 
ation ceases  to  bo  dangerous.  There  is  no  longer  any  danger  of 
those  dreadful  slips,  which  chance  alone  could  prevent,  when  the 
operator  is  so  rash  as  to  pull,  blindfold  as  it  were,  with  a  single  in- 
strument. 

1172.  When  one  of  the  bones  breaks  or  gives  way,  the  crotchet 
must  be  again  applied,  upon  a  firmer  part.  Some  advise  that  the 
point  should  be  directed  in  front  towards  the  pubes.  Others  have 
directed  it  to  be  applied  behind,  for  the  purpose  of  more  easily 
drawing  the  head  down  through  the  superior  strait ;  but  it  is  not 
easy  to  lay  down  general  rules  on  this  subject ;  we  must  act  in  either 
way,  according  to  circumstances.  Should  the  head  rise  up  again, 
strongly,  whenever  we  cease  to  pull  with  the  crotchet  fixed  at 
the  back  part,  it  would  be  well  to  follow  M.  Duges's  plan  and  fix 
a  second  crotchet  in  front,  while  the  head  continues  to  be  held  down 
with  the  first ;  this  may  be  got  higher  up,  or  a  third  instrument  may 


THE  CROTCHET.  527 

be  attached,  while  the  head  is  kept  as  low  down  as  possible  with 
the  others. 

To  force  the  base  of  the  cranium  to  clear  the  superior  strait,  we 
sometimes  meet  with  obstacles  that  are  excessively  difBcult  to  over- 
come. The  bones  of  which  it  is  composed  do  not  bend  like  those 
of  the  vault  of  the  cranium,  and  the  crotchet  is  quite  as  incapable 
of  lessening  its  size  as  the  forceps ;  it  is  only  by  engaging  it  in  an 
oblique  direction  that  we  most  generally  succeed  in  extracting  it 
in  cases  where  the  antero-posterior  diameter  does  not  exceed  two 
inches  or  two  inches  and  a  quarter. 

Perhaps  the  terebellum  of  M.  Duges  might  be  beneficially  em- 
ployed in  such  cases  as  these :  this  is  a  sort  of  cooper's-turrel,  which 
is  capable  of  perforating  the  bones  and  cartilages,  of  breaking  up 
the  base  of  the  cranium  so  as  to  render  it  flexible,  and  of  acting  as 
a  substitute  for  most  of  the  cephalatomes. 

1173.  M.  Baudelocque,  Jun.  has  lately  constructed  a  forceps, 
the  object  of  which  is  to  overcome  all  these  difficulties,  and  to  ren- 
der all  the  perforators  and  most  of  the  sharp  crotchets  superfluous. 
The  clams  of  this  forceps  are  not  fenestrated,  and  are  but  slightly 
curved ;  so  that  by  being  closed  they  may  pass  through  a  strait  that 
does  not  exceed  fifteen  lines  in  its  small  diameter;  through  the 
handles  of  the  instrument  passes  a  screw,  which  enables  them  to 
be  closed  with  such  force  that  the  head  of  the  fcetus  will  be  easily 
reduced  to  any  desirable  dimensions  without  exposing  the  woman 
to  the  least  risk.  This  instrument  appears  to  me  to  be  an  ingenious 
one ;  but  previously  to  forming  a  decided  opinion  concerning  it,  I 
should  like  to  have  an  opportunity  of  seeing  it  employed  in  a  case 
of  labour. 

1174.  However,  when  the  base  of  the  cranium  has  reached  the 
excavation,  the  head  may  be  taken  hold  of  with  the  hands,  and  the 
crotchet  is  of  no  further  use,  unless  it  should  be  applied  to  the  trunk, 
supposing,  moreover,  that  the  blunt  crotchet  when  applied  to  the 
axillae  should  prove  incompetent  to  the  extraction. 

In  this,  as  in  all  cases  where  the  head  is  completely  separated 
from  the  body,  there  are  only  three  points  upon  the  trunk  which 
can  bear  the  action  of  the  sharp  crotchet:  these  are  the  spine, 
the  sternum,  and  the  ribs,  and  even  the  latter  is  a  very  insecure 
hold,  so  that  the  whole  of  the  ribs  of  one  side  are  sometimes  found 
to  give  way  one  after  the  other,  as  soon  as  a  certain  degree  of 
extractive  force  has  to  be  employed.  It  is  therefore  particularly 
upon  the  vertebral  column  that  we  should  endeavour  to  fix  the  point, 
and  then  act  as  we  should  have  to  do  provided  it  were  attached 
upon  the  head. 


528  THE  CROTCHET. 

1176.  There  is  one  single  circumstance  which  seems  tome  to 
require  the  use  of  the  sharp  crotchet  upon  the  trunk  in  a  pelvis  pre- 
sentation ;  it  is  where  the  lower  limbs  have  been  separated  from  the 
body,  or  where  they  are  wanting  in  consequence  of  monstrous  con- 
formation, or  where  they  do  not  admit  of  a  hold  being  taken,  suffi- 
ciently firm  to  pull  the  body  down  by  them.  In  such  cases  the 
crotchet  should  be  applied  to  the  pubis,  the  crista  of  the  ilium,  or 
what  is  still  better,  to  the  sacrum. 


SECTION  8. 

Of  the  Extraction  of  the  Head  when  it  has  been  left  alone  in  the 
Genital  Passages. 

1 176.  When  the  head  is  separated  from  the  trunk,  and  left  in  the 
pelvis,  it  almost  always  happens  in  consequence  of  its  being  badly 
situated  at  the  superior  strait,  or  because  the  accoucheur  was  not 
skilful  enough  to  disengage  it  in  time  :  in  this  case  the  detachment  no 
sooner  takes  place  than  the  head  becomes  in  some  sort  movable  in 
the  womb,  which  soon  brings  it  to  the  best  possible  situation  ;  a  few 
pains  then  succeed  in  expelling  it,  and  the  assistance  of  art  is,  for  the 
most  part,  unnecessary.  In  other  cases  the  detruncation  of  the  foetus 
takes  place  because,  having  been  dead  for  some  time,  it  is  already . 
nearly  in  a  putrid  state.  If  we  wait  for  a  short  time,  under  these 
circumstances,  the  brain  shrinks,  the  bones  of  the  cranium  become 
very  movable,  may  over-ride  each  other,  and  although  at  first  the 
pelvis  might  have  been  too  narrow,  the  head  nevertheless  escapes 
spontaneously  at  last ;  upon  these  results,  and  also  upon  the  evils 
that  have  often  been  found  to  follow  upon  unskilful  attempts  to 
hasten  the  delivery,  the  English  practitioners  cited  above  found  the 
precept,  that  the  expulsion  of  the  head  should  be  confided  to  the 
powers  of  nature  alone ;  but  as  the  labour  has  already  lasted  too 
long,  and  as  in  some  instances  it  would  be  necessary  to  wait  several 
days  ;  as  the  extreme  irritation  of  the  uterus  would  expose  it  to  the 
hazard  of  becoming  inflamed,  and  the  woman  might  die  of  exhaus- 
tion before  the  escape  of  the  head,  it  would  be  imprudent  and  unrea- 
sonable not  to  give  proper  assistance.  We  ought  not,  says  M.  Des- 
ormeaux,  to  act  with  inconsiderate  haste  ;  there  arc  cases  where  it 
is  proper  to  temporise  ;  it  may  be  necessary  to  restore  the  strength 
by  means  of  some  aliment,  a  little  wine,  or  other  strengthening  arti- 
cles. Baths  and  antiphlogistics,  &c.  may  be  required  previously 
to  any  other  recourse,  in  consequence  of  an  incipient  inflammation 
of  the  womb,  or  peritoneum,  duj. 


EXTRACTION  OF  THE  HEAD.  539 

In  cases  where  the  hand  alone  may  suffice,  that  is  to  say,  where 
the  head  is  small,  or  requires  to  be  placed  in  a  better  situation  for 
descending,  an  attempt  should  be  made  to  get  hold  of  the  lower 
jaw  ;  then,  after  having  brought  the  occipito-mental  diameter  into 
line  with  the  axes,  it  should  be  drawn  down  as  far  as  possible,  coin- 
cidently  with  the  efforts  of  the  womb  or  those  of  the  patient. 

Next  to  the  hand  the  forceps  is  the  best  and  safest  resource  that 
we  have  ;  but  it  is  not  always  possible  to  apply  it,  while  the  head  is 
still  at  the  superior  strait,  and  in  some  cases  its  employment  does 
not  always  obviate  the  necessity  of  having  recourse  to  craniotomy, 
or  even  to  the  sharp  crotchet.  It  is  true,  that  for  the  purpose  of 
avoiding  the  latter  measures,  a  great  variety  of  extractors  (tire- 
tetes)  have  been  proposed  ;  but  none  of  them  can  be  regarded  as 
good  substitutes.  The  double  cross  of  Bacquie,  the  bascule  of 
Levret,  the  basiocester  of  Metzler,  the  sling  of  Mauriceau,  the  T 
ofStein,  the  nets  of  Amand,  the  cap  proposed  by  M.  Desormeaux, 
Sen.  the  forceps  with  three  branches  of  Levret,  the  small  piece  of 
stick,  to  the  middle  of  which  is  attached  a  string,  or  the  one  made 
of  iron  fixed  to  the  end  of  the  metallic  rod  in  such  a  way  that  it 
may  be  introduced  parallel  to  the  rod,  and  after  reaching  the  in- 
terior of  the  cranium,  be  altered  so  as  to  stand  crosswise  to  it,  the 
invention  of  which  is  attributed  to  Danavia,  and  also  to  Assalyii, 
and  which  has  been  too  much  praised  by  many  authors  ;  all  of  these 
means  have  ceased .  to  be  made  use  of  at  the  present  day.  The 
crotchet  planted  somewhere  near  the  occipital  foramen,  in  the  up- 
per jaw,  or  in  some  other  firm  part,  whilst  the  opposite  part  of  the 
head  is  supported  with  the  fingers,  is  in  this,  as  in  some  other  cases, 
the  last  resource ;  but,  nevertheless,  it  forms  the  only  really  effi- 
cient extractor  in  all  cases  where  the  hand,  the  common  forceps, 
the  toothed  forceps,  the  extracting  forceps  with  three  branches,  or 
the  crotchet  forceps,  or  the  forceps  of  M.  Baudelocque,  Jun.  are 
cither  inapplicable  or  insufficient  for  the  delivery  of  the  head. 


3  R 


530 


'^CHAPTER  VII. 

Of  the  JVatural  Phenomena  which  follow  the  Delivery 
of  the  Foetus. 

ARTICLE  I. 
Of  the  delivery  of  the  ^fter-birth. 

The  placenta  and  the  membranes  are,  after  the  birth  of  the  child, 
called  the  after-birth,  and  their  expulsion,  escape,  or  extraction  is 
(in  France)  called  Delivery.  Like  child  birth,  this  is  a  natural 
function  ;  and  like  it,  this  function  may  also  be  simple  or  complex, 
or,  if  the  expression  be  preferred,  natural  or  preternatural^  spon- 
taneous or  artificial. 

SECTION  1. 
Of  simple  or  natural  delivery  of  the  Afterbirth. 

All  the  phenomena  of  simple  delivery  are  rcferrublc,  1 .  To  the 
detachment  of  the  placenta ;  2.  To  its  expulsion  from  the  genital 
organs. 

1177.  First  stage.  The  ovum  becomes  detached  during  the 
progress  of  a  labour,  and  especially  towards  the  conclusion,  when  the 
waterd  have  gone  off.  Being  in  some  sort  an  inert  mass,  its  adhe- 
sion must  necessarily  be  destroyed  during  the  alternate  contractions 
and  dilations  of  the  womb,  unless  the  labour  be  so  prompt  as  to 
require  almost  no  effort  of  the  organism,  or  unless  there  be  some 
preternatural  adhesions. 

The  cause  of  this  detachment  is  found  in  the  entire  uterus,  and 
not  merely  in  the  orbicular  muscle  which  Ruysch  supposed  he  had 
discovered.  Sometimes  the  detachment  takes  place  in  such  a  way 
that  thf!  fa'tal  surface  of  the  placenta  presents  first  at  the  vulva,  and 
the  blood,  cither  fluid  or  coagulated,  collects  behind  the  spongy  sur- 


TABLE  IV. 

Labours  observed  6y  MM.  Bland,  Merbikaiv,  Dewees,  Arnell, 
Moore,  Nceoele,  Boer,  Mesdames  Boivin  and  Lachafelle, 
and  at  the  Dublin  Lying-in  Hospital. 

^ 

.2 

— 

'6 

Messrs  Dewees,  Ar- 
nel  and  Moore. 

Madame  Boivin. 

Merriman.     .     .     . 

Dublin  Hospital.     . 

Madame  Lachapelle. 

Noegele 

Boer 

about 
35,000 

20,517 

1,813 

106,766 

37,895 

415 

15,608 

or 

6,555  ca 

about 
200 

153 

22 
2,110 

444 

6 

Uncer. 
in 
ies   92 

Only 
1 

3 

1 

26 

5 

1 

1 

Uncer. 
Uncer. 
929 
55,804 
19,474 
199 
Uncer. 
Uncer. 

Uncer. 
Uncer. 

884 
50,962 
18,421 

216 
Uncer. 
Uncer. 

Uncer. 
Uncer. 
Uncer. 

9,497 

2,291 

31 

Uncer. 

463 

Total.     . 

224,569 

3,027 

37 

1 

76,406 

70,483 

12,282 

Thus  tliere  were  3027  twins,  37  triplets,  and  only  one  case  where  4  children 
were  produced  at  a  birth  in  about  200,000  births. — 146,889  yield  76,406  boys 
and  70,483  girls ;  and  out  of  a  total  of  160,269  children,  12,282  were  born  dead  ; 
M.  Schweighauser  reports  a  second  case  of  4  at  a  birth  ;  the  public  papers  hare 
mentioned  a  third  instance  in  France  of  late  years;  Merriman  speaks  of  a  fourth, 
which  occurred  in  Worcestershire,  in  1820 ;  and  Osiander  says,  according  to  a 
letter,  that  a  woman  was  delirered  of  5  living  children  near  Oporto  in  1788. 

DELIVERY  OF  THE  AFTER-BIRTH.  531 

face  of  the  cake,  which  is  concave,  like  the  bottom  of  a  bottle ; 
sometimes  it  is  effected  gradually,  proceeding  from  the  centre  to 
the  circumference,  or  it  may  begin  on  the  edge,  and  if  the  involucra 
resist  long,  the  smooth  or  internal  surface  may  become  the  outer 
one,  and  the  blood  being  confined  on  the  outside  of  the  membranes,  (* 
does  not  escape  until  after  the  expulsion  of  the  after-birth,  the  size 
of  which  it  sometimes  surprisingly  augments.  , 

At  other  times,  in  detaching  itself,  the  placenta  rolls  up  in  the 
shape  of  a  cylinder  or  cornet  d^oublie.  In  that  case  it  presents  by 
its  uterine  surface  or  by  its  edge  to  the  several  passages  ;  the  blood, 
not  being  confined,  flows  out  at  the  vulva  as  fast  as  it  is  poured  into 
the  womb,  and  commonly  ceases  to 'flow  as  soon  as  the  placenta  is 
delivered. 

Second  stage.  When  once  detached,  the  placenta  presses  upon 
the  OS  uteri,  engages  in  the  orifice,  which  it  irritates,  and  the  womb, 
which  is  irritated  by  its  presence,  becomes  more  and  more  constrict- 
ed, contracts,  and  soon  forces  it  to  pass  into  the  vagina.  When 
there,  it  soon  gives  rise  to  a  sensation  of  uneasiness,  tenesmus,  or 
bearing  down,  which  still  solicit  the  contractions  of  the  womb,  and 
bring  into  play  the  efforts  of  the  abdominal  muscles.  The  diaphragm 
and  muscles  of  the  belly  react  upon  the  abdominal  viscera  and 
womb,  as  if  for  the  expulsion  of  the  foetus,  and  the  placenta  clears 
the  inferior  strait. 

Some  persons,  and  among  them  M.  Desormeaux,  divide  this  pe- 
riod of  expulsion  into  two  stages.  It  is  true,  that  in  order  to  pass 
from  the  womb  into  the  vagina,  the  after-birth  sometimes  requires 
so  considerable  a  degree  of  dilation  of  the  os  uteri,  that  a  particular 
stage  might  be  made  of  it,  and  that  it  may  afterwards  remain  so 
long  in  the  passage  that  its  entire  expulsion  really  constitutes  a  dis- 
tinct period  ;  but  as  these  two  stages  are  far  from  being  always  so 
distinctly  marked,  it  appears  to  me  that  they  may  without  inconve- 
nience be  confounded  together.  However,  this  is  an  affair  of  choice, 
not  of  necessity. 

If  the  labour  have  been  a  long  one,  if  the  woman  be  strong,  if  the 
means  of  art  have  been  applied  for  the  extraction  of  the  child,  and  if 
the  womb  be  in  a  state  of  considerable  energy,  the  placenta  falls  into 
the  vagina  and  presents  itself  at  the  vulva  almost  immediately  after 
the  delivery  of  the  child.  In  opposite  cases,  the  delivery  of  the 
placenta  does  not  take  place  for  half  an  hour,  and  sometimes  even 
for  several  hours.  It  may  also  happen,  that  it  shall  not  take  place 
for  a  whole  day,  or  even  for  several  days.  This  difference  is  easily 
explained  :  in  the  first  case,  the  ovum  which  has  been  long  detach- 
ed descends  whole,  along  with  the  fcetus.     'i'he  womb,  contracting 


632  DELIVERY  OF  THE  PLAGENTA. 

strongly  in  proportion  as  it  empties  itself,  simultaneously  throws 
out  both  the  child  and  placenta.  In  the  second,  the  promptitude  of 
the  delivery  of  the  child  is  so  great,  that  the  womb  has  not  had  time 
to  break  up  the  adhesions  of  the  ovum,  or  to  contract  sufficiently. 
Until  the  cavity  of  the  womb  becomes  so  diminished  that  the  after- 
birth fills  it  quite  up,  it  may  remain  above  the  orifice.  When  the 
child  has  just  passed  through  the  os  uteri,  provided  the  placenta  be 
•detached  at  the  time,  and  urged  onwards  by  the  uterus,  nothing  can 
prevent  it  from  descending;  but  if  the  orifice  closes  before  the  body 
of  the  organ  becomes  reduced  in  proportion,  the  after-birth  remains 
shut  up  as  it  were  in  the  uterine  cavity,  and  cannot  escape  for  a 
considerable  length  of  time,  although  its  adhesions  may  have  been 
broken  up  from  the  beginning. 

1 178.  Although  the  organism  generally  suffices  to  finish  the  ex- 
pulsion of  the  after-birth  when  it  has  reached  the  excavation,  sonie 
cases  are,  however,  observed  in  which  it  would  remain  there  for  an 
indefinite  period,  provided  its  escape  were  not  promoted  by  artificial 
means.  It  is  on  account  of  this  tedious  slowness,  and  to  relieve 
the  woman  of  her  fatigue  and  uneasiness  of  mind,  that  a  natural  or 
simple  case  of  delivery  of  the  placenta  is  scarcely  ever  wholly  aban- 
doned to  the  efibrts  of  nature.  De  la  Motte,  Deventer,  Peu,  and 
some  modern  authors,  are  scarcely  willing  that  we  should  wait  for 
it  for  half  an  hour:  according  to  them,  if  we  do  not  act  at  once,  the 
orifice  closes,  and  may  retain  the  after-birth,  from  whence  accidents 
of  greater  or  less  severity  may  ensue.  Levret  and  Smellie,  Baude- 
locque,  and  almost  all  practitioners  of  the  present  day,  advise  us, 
on  the  contrary,  not  to  act  until  the  placenta  is  completely  detached, 
and  presents  itself  spontaneously  at  the  orifice  of  the  womb. 

Both  of  these  doctrines,  if  taken  according  to  the  very  letter,  ap- 
pear to  me  to  be  equally  incorrect.  The  practice  of  the  ancients, 
if  followed  without  exception  in  all  cases,  would  doubtless  some- 
times be  dangerous;  but  I  am  induced  to  believe  that  at  the  present 
day  we  have  fallen  into  an  opposite  extreme ;  by  endeavouring  to 
follow  nature  as  closely  as  possible,  the  end  which  the  accoucheur 
ought  to  hold  in  view  has  been  lost  sight  of. 

Besides,  if  it  is  proper  to  act  as  soon  as  the  placenta  is  detached, 
I  do  not  see  wherefore  the  delivery  should  be  so  frequently  deferred; 
for  except  in  a  few  cases,  this  detachment  takes  place  previously  to 
the  expulsion  of  the  child.  I  can  scarcely  conceive,  indeed,  how 
the  womb  can  be  reduced  to  a  fourth  or  fifth  part  of  its  volume, 
without  destroying  the  delicate  filaments  which  connect  it  to  the 
ovum.  Most  of  the  facts  that  are  cited  to  show  that  the  adhesions 
of  the  placenta  continue  to  exist  after  the  birth  of  the  child,  are  any 


DELIVERY  OF  THE  PLACENTA.  533 

thing  rather  than  conclusive,  and  do  not  seem  to  have  been  properly 
interpreted. 

I  know  that  when  the  cord  has  been  pulled  at  an  improper  time, 
it  has  been  found  to  occasion  the  inversion  of  the  womb;  but,  in  the 
first  place,  this  accident  is  a  very  rare  one ;  and  next,  it  does  not 
prove  that  the  union  of  the  placenta  and  womb  was  maintained  at 
the  time;  for,  if  such  tractions  are  i>erforraed  while  the  womb  is  soft 
and  uncontracted,  whether  the  adhesions  of  the  placenta  be  contin- 
ued or  not,  they  occasion  the  woman  to  bear  down,  and  it  is  very 
natural  that  the  womb  should  then  be  inverted.  The  cord  has  often 
been  pulled  so  as  to  break  it  oft*,  so  as  to  give  pain  to  the  woman, 
and  make  her  feel  a  dragging  sensation  within,  and  the  placenta, 
notwithstanding,  has  not  been  moved  at  all.  All  this  is  doubtless 
true  ;  but  without  speaking  of  the  pretended  uterine  cristae  which 
have  formerly  been  so  much  spoken  of,  does  the  womb  never  con- 
tract, except  in  a  regular  manner,  upon  the  secundines  ?  Does  it  not, 
on  the  contrary,  mould  itself,  in  some  sort,  upon  the  anfractuosities 
of  the  placenta,  so  as  to  msike  its  extraction  somewhat  difficult  ? 
and  then,  are  we  sure  that  the  extracting  force  has  been  apphed  in 
the  best  possible  direction,  and  exactly  to  the  proper  extent ;  have 
not  the  faults  of  the  accoucheur  been  most  commonly  attributed  to 
the  adhesion  of  the  placenta  ?  In  ray  amphitheatre  I  have  many 
times  seen  the  students  leave  off"  pulling  at  the  cord  from  a  convic- 
tion that  the  placenta  was  not  detached,  whereas  I  had  only  to  pull 
in  a  rather  more  methodical  manner  than  they  did,  in  order  to  termi- 
nate the  delivery  at  once,  and  without  difficulty,  in  their  presence. 
In  a  woman  who  came  to  be  delivered  at  the  Hospital  de  TEcoie^ 
and  who  had  a  flooding,  the  cord  had  already  been  pulled  so  as  to 
break  it  off".  I  introduced  my  hand  into  the  womb  and  found  no 
adhesion  at  all.  Being  called  to  visit  a  woman,  in  the  Rue  de  la 
Montagne-Sainte  Genevieve,  whose  child  had  been  born  six  hours, 
I  learned  that  all  imaginable  efforts  had  been  made  to  bring  away 
the  placenta.  The  physician  had  asked  for  assistance  only  because 
he  was  convinced  that  the  hand  must  be  introduced  into  the  womb 
in  order  to  destroy  the  adhesions  of  the  placenta.  He  repeated  his 
attempts  in  my  presence,  and  I  soon  found  he  would  not  succeed. 
I  now  took  hold  of  the  cord,  and  found  that  there  was  no  particular 
difficulty  in  bringing  away  the  after-birth.  I  have  so  frequently 
met  with  these  cases  of  supposed  adhesion;  I  have  so  often  intro- 
duced my  hand  into  the  uterine  cavity  with  the  design  of  destroying 
them,  when  I  was  informed  that  they  existed,  and  when  in  fact  they 
had  no  existence ;  and  from  reasoning  it  is  so  difficult  to  admit  them, 
that  I  do  not  hesitate  to  look  upon  their  occurrence  as  very  rare. 


534  DELIVERY  OF  THE  PLACENTA. 

How  can  we  conceive,  in  fad,  that  they  could  give  way  so  easily 
under  the  feeble  contractions  that  take  place  after  the  expulsion  of 
the  child,  after  having  resisted  the  violent  efforts  of  the  close  of  the 
expulsive  stage  of  the  labour  ?  1  believe,  therefore,  that  if  it  is  not 
prudent  to  deliver  the  after-birth  immediately  after  the  escape  of  the 
child,  we  ought  to  look  for  another  reason  for  the  caution,  than  the 
non-detachment  of  the  placenta;  that  the  object  of  the  uterine  con- 
tractions and  their  effect  is  far  more  to  push  this  body  gradually 
through  the  os  uteri  and  into  the  vagina,  than  to  break  up  its  union 
to  the  womb  ;  that  it  is  not  indispensably  necessary  for  the  woman 
to  have  colic  pains  and  dragging  sensations  in  the  loins  before  the 
accoucheur  delivers  her;  and  that  there  are  some  disadvantages  in 
not  acting  as  soon  as  a  favourable  opportunity  presents  itself. 

Being  (in  1823)  still  imbued  with  the  prevailing  ideas  upon  this 
subject,  I  used  to  wait  till  pains  came  on  before  I  proceeded  to  act, 
and  1  stopped  as  soon  as  1  perceived  the  slightest  resistance  ;  and 
in  the  short  space  of  six  months  I  was  obliged  to  wait,  on  one  oc- 
casion ten  hours,  on  a  second  twenty-four,  on  a  third  thirty-six,  and 
on  a  fourth  forty-eight  hours,  before  the  placenta  was  delivered,  and 
in  the  last  case,  was  even  obliged  after  all  to  introduce  the  hand  in 
search  of  the  placenta.  Since  that  time  I  have  never  been  obliged 
to  wait  more  than  one  hour :  for  me  it  suffices  when  the  womb  has 
contracted  and  become  hard,  even  although  the  woman  have  felt  no 
pain,  nor  dragging  sensation,  and  up  to  the  present  time  I  have  had 
good  reason  to  be  satisfied  with  my  mode  of  proceeding. 

1179.  Thus,  after  having  given  the  first  necessary  attentions  to 
the  child,  we  return  to  the  mother,  and  if  the  hand  applied  to  the 
hypogastrium  feels  the  womb  contracted  with  a  certain  degree  of 
force,  we  assist  the  delivery  of  the  placenta  ;  when  the  uterine 
globe  does  not  form,  we  ought  to  wait,  or  make  use  of  the  measures 
proper  to  remove  inertia. 

To  favour  the  expulsion  of  the  after-birth,  the  cord  is  to  be  taken 
hold  of  with  the  right  hand,  twisting  it  round  the  root  of  the  mid- 
dle and  ring  fingers,  and  then  bringing  it  betwixt  the  thumb  and 
index  finger  ;  or  it  is  merely  taken  hold  of  with  the  hand  after 
being  wrapped  in  a  piece  of  linen,  and,  always,  as  near  as  possible 
to  the  vulva  ;  two  or  three  fingers  of  the  left  hand  are  then  to  be 
slipped  into  the  vagina,  passing  them  up  under  the  symphysis  of  the 
pubis  to  the  orifice  of  the  womb,  or  as  fur  as  the  root  of  the  cord ; 
as  these  fingers  are  to  form  a  sort  of  gutter  or  pulley,  I  prefer 
three  rather  than  only  two  fingers,  because  as  ti)e  niedius  forms  the 
bottom  of  the  groove,  the  index  and  annularis  easily  prevent  the 
cord  from  slipping  oft' to  tlie  right  or  left,  whereas,  if  only  two  are 


DELIVERY  OF  THE  PLACENTA.  535 

itiade  irae  of,  the  cord  almost  always  separates  them,  and  therefore 
it  would  be  quite  as  well  to  place  them  crosswise,  in  the  upper  part 
of  the  vulva,  as  is  the  practice  with  some  persons. 

The  way  to  derive  the  greatest  possible  advantage  from  them  is 
to  pass  them  up  as  far  as  the  foetal  surface  of  the  placenta,  even 
should  that  be  above  the  os  uteri,  and  then  make  them  act  like  a 
lever  of  the  first  kind.  The  back  of  them  rests  against  the  top  of 
the  pubic  arch,  and  while  the  other  hand  is  drawing  the  cord  along 
the  axis  of  the  inferior  strait,  they  are  pressed  against  the  root  of 
the  cord  ;  then  by  a  sort  of  see-saw  motion,  communicated  by 
the  gradual  raising  of  the  wrist,  they  force  the  placenta  along  from 
above  downwards  and  from  before  backwards,  towards  the  point  of 
the  sacrum,  and  in  the  axis  of  the  superior  strait. 

This  stage  of  the  operation  is  the  most  delicate,  the  most  impor- 
tant, and  most  difficult  to  perform  well.  The  womb  is  sometimes 
so  bent  forwards  that  if  the  fingers  do  not  push  the  cord  almost 
directly  backwards,  the  placenta  remains  immovable  ;  at  other  times 
they  must  be  directed  a  little  to  the  left  or  right,  because  the  os 
uteri  is  deviated  more  or  less  to  one  side  or  the  other  ;  the  axis  of 
the  'Womb,  besides,  presents  a  thousiind  shades  which  it  would  be 
necessary  to  apprehend,  and  which  practice  alone  can  enable  one  to 
recognize.  This  is  the  reason  why  a  delivery  deemed  by  one  ac- 
coucheur to  be  impossible,  will  often  be  quite  a  simple  case  to 
another  person  ;  and  why  this  operation,  in  appearance  so  easy  and 
unimportant,  deserves,  notwithstanding,  the  most  minute  attention 
from  those  who  desire  to  perform  it  well.  Should  the  pulley  (com- 
posed of  the  ends  of  the  fingers)  be  not  well  placed  ;  should  the 
lever  represented  by  the  fingers  not  be  well  situated,  or  not  act  pro- 
perly, the  after-birth,  from  being  arrested  by  the  upper  edge  of  the 
pubis  or  the  posterior  surface  of  the  symphysis,  would  not  come 
down  ;  the  whole  of  the  power  would  be  directed  upon  the  root  of 
the  cord,  which  would  certainly  break,  or  upon  some  part  of  the 
uterine  orifice,  whence  that  dragging  and  pain  which  give  rise  to  the 
idea  of  preternatural  adhesions- 
Be  this  as  it  may,  when  the  placenta  has  come  down  into  A6 
vagina,  the  fingers  of  the  left  hand  should  be  continued  in  the  same 
situation  they  occupied  before,  but  merely  so  as  to  favour  the  escape 
of  the  membranes  which  might  not  have  cleared  the  os  uteri,  and 
to  form  a  sort  of  inclined  plane,  along  the  inferior  surface  of  which 
the  whole  after-birth  might  glide  while  pulled  by  the  right  hand 
along  the  axis  of  the  inferior  strait.  In  this  way  the  Irand  that  holds 
the  cord  may  be  raised  upwards  without  fear  of  being  embarrassed 
by  the  pubic  arch,  and  we  avoid  being  stopped  by  the  inferior  sur- 


536  DELIVERY  OF  THE  PLACENTA. 

face  of  the  perineum ;  which  is  an  inconvenience  frequently  met 
with  when  the  placenta  is  pulled  along  in  what  is  properly  called 
the  axis  of  the  strait,  rather  than  in  that  of  the  vulva. 

As  soon  as  the  after-birth  appears  at  the  vulva,  the  left  hand  is 
placed  underneath  it,  crossways,  and  supine,  in  order  to  sustain  it ; 
the  right  hand,  in  pronation,  takes  it  with  the  ends  of  all  the  five 
fingers,  and  rolls  it  four  or  five  times  round,  drawing  it  moderately 
and  slowly  downwards ;  without  these  rotatory  motions  the  mem- 
branes might  separate  from  the  placenta,  and  remain  within  the 
female  organs,  while  if  twisted  in  this  way  they  are  collected  to- 
gether and  resemble  a  rope,  and  become  easy  to  extract. 

During  these  various  maneuvres,  the  womb  rarely  fails  to  contract 
with  more  or  less  force,  and  seems  to  assist  the  accoucheur ;  the 
woman  herself  is  generally  induced  to  make  some  efforts  as  soon  as 
the  womb  has  descended  into  the  vagina,  and  these  efforts,  rigo- 
rously speaking,  would  suffice  to  terminate  the  delivery,  provided 
they  always  took  place  ;  but,  in  reality,  they  are  not  very  necessary, 
and  may  often  be  injurious  :  they  only  favour  the  expulsion  of  the 
placenta  indirectly,  and  are  capable  of  directly  producing  the  descent 
or  inversion  of  the  womb ;  the  woman  ought  therefore  to  be  urged 
to  moderate  rather  than  enforce  them  ;  it  would  not  only  be  useless 
or  ridiculous,  but  also  in  some  cases  very  dangerous  to  administer 
sternutatories,  or  advise  her  to  blow  into  a  bottle,  or  in  her  hands, 
or  on  to  a  grain  of  salt  to  hasten  the  delivery  ;  for  if  ever  such  mea- 
sures have  any  effect,  it  is  merely  by  occasioning  certain  succussions, 
or  those  straining  efforts  that  I  just  now  was  condemning. 

The  extracting  force  necessary  in  this  operation  ought  never  to 
be  carried  so  far  as  to  rupture  the  cord :  if  the  placenta  resists,  the 
cause  of  it  ought  to  be  sought  for  in  the  direction  of  the  orifice,  its 
closure,  &c. ;  we  should  wait,  or  else  pull  in  another  direction,  and 
be  assured  that  force  is  never  necessary  to  enable  us  to  triumph 
over  such  obstacles. 

1 1 80.  It  is  recommended  that  the  after-birth  should  be  examined 
as  soon  as  it  is  delivered,  to  make  sure  that  no  part  of  it  is 
left  within  the  genital  organs  :  it  will  be  well  to  follow  this  advice, 
no  doubt,  whenever  the  delivery  has  been  attended  with  some  diffi- 
.culty,  or  any  peculiar  circumstances ;  but  in  other  cases,  it  would 
be  puerile  to  trouble  ones-self  about  it,  especially,  considering  that 
even  should  some  small  pieces  of  the  placenta  or  shreds  of  mem- 
branes be  left  in  the  womb,  we  should  not  be  authorized  oh  that 
account  to  introduce  the  hand  in  search  of  them. 


COMPLICATED  DELIVERY  OF  PLACENTA.  537 

SECTION  2. 

Complicated  Delivery  of  the  After-birth. 

Inertia,  hemorrhage,  convulsions,  syncope,  the  rupture  of  the 
cord,  preternatural  adhesions,  an  encysted  state  of  the  placenta,  ex- 
cessive size  of  it,  and  a  spasmodic  contraction  of  the  os  uteri,  consti- 
tute a  number  of  accidents  which  sometimes  complicate  the  delivery, 
and  require  that  we  should  hasten  or  protract  the  term  of  its  ex- 
clusion. 

1181.  Inertia  of  the  loomh,  after  deUvery  of  the  child,  is  more 
particularly  observed  to  happen  in  women  who  are  weak  and  ex- 
hausted by  flooding  or  the  fatigue  of  a  protracted  labour  ;  it  is  also 
met  with  after  too  sudden  a  delivery  of  the  child,  and  in  these 
different  cases  it  requires  a  caution  which  is  peculiar  in  each.  Some- 
times the  proper  remedy  is  a  little  good  wine,  sometimes  a  little 
light  and  analeptic  aliment,  at  others  rest ;  but  it  is  always  useful  to 
excite  the  womb  through  the  epigastrium,  by  rubbing  and  pressing 
it  with  the  ends  of  the  fingers,  and  even  by  compressing  it  with  a 
certain  degree  of  force,  alternately  from  above  downwards,  from 
side  to  side,  and  from  before  backwards,  as  if  with  a  view  to  mass 
it,  and  oblige  it  to  contract  its  dimensions.  Pulling  at  the  cord,  if 
attempted  previously  to  the  cessation  of  the  inertia,  would  hazard 
the  production  of  an  inversion  of  the  womb  less,  perhaps,  in  conse- 
quence of  any  remaining  adhesions  of  the  placenta  than  from  the 
direct  pressure  of  the  abdominal  viscera  upon  a  soft  and  contracted 
bag  ;  transmitted  to  the  internal  surface  of  the  gestative  organ,  they 
might,  also,  invite  an  affluxion  of  blood  to  it,  and  give  rise  ta 
hemorrhage.  They  must  therefore  be  dispensed  with,  unless  some 
serious  accident  obliges  us  to  act  otherwise.  Thus,  inertia  of  the 
womb  ought  to  be  classed  among  the  complications  which  retard 
the  delivery  of  the  placenta, 

1182.  The  volume  of  the  after-birth  is  in  some  instances  the  only 
cause  that  retards  its  expulsion.  But  this  excess  of  size  is  often 
more  apparent  than  real,  and  depends  on  the  blood  being  amassed 
behind  the  membranes.  Where  the  placenta  is  really  too  large, 
moderate  and  skilful  tractions  almost  always  suffice ;  if  not,  we  must 
wait,  and  the  natural  retraction  of  the  uterus  at  last  renders  its  ex- 
traction easy.  In  the  second  case,  which  is  the  most  common,  if 
the  contractions  of  the  womb  and  force  carefully  exerted  upon  the 
cord  are  inefficacious,  the  membranes  may  be  torn,  or  the  placenta 

3S 


538  COMPLICATED  DELIVERY  OF  PLACENTA. 

itself  perforated  with  the  fingers,  and  a  passage  made  for  the  fluids 
behind  them. 

We  should,  moreover,  have  reason  to  suspect  the  existence  of  this 
state  of  things  should  the  womb  be  found  to  preserve  a  larger  size 
than  common  above  the  pubis,  although  not  deficient  either  in  firm- 
ness or  energy  ;  were  the  after-birth  already  in  the  vagina,  the  diag- 
nosis, and  the  application  of  suitable  means  would  be  too  easy  to  be 
spoken  of  at  greater  length  in  this  place.  Upon  the  whole,  exces- 
sive volume  of  the  appendages  of  the  foetus  scarcely  constitutes  one 
of  the  accidents  of  delivery^  unless,  indeed,  it  be  coincident  with 
some  other  complication. 

1 183.  I  may  say  the  same  of  the  spasmodic  contraction  of  the  oa 
uteri.  In  fact,  it  is  diflScult  to  conceive  that  an  opening,  through 
whi6h  a  child  has  just  passed,  can  contract  spasmodically  to  such  a 
degree  as  to  oppose  the  escape  of  the  placenta.  To  admit  such  an 
obstacle,  we  ought,  which  is  not  the  case,  to  have  some  very  authentic 
instances  of  the  kind.  Besides,  as  it  is  not  a  part  of  the  nature  of 
spasm  to  persist,  we  might,  should  such  a  case  occur,  refer  it  to  the 
efiect  of  time,  and  content  us  with  administering  some  composing  or. 
antispasmodic  medicines,  according  to  circumstances. 

1 184.  It  is  evidently  the  natural,  but  somewhat  precipitate  closure 
of  the  OS  uteri,  which  has  been  qualified  as  the  spasmodic  contrac- 
tion :  considered  under  this  point  of  view  it  is  a  circumstance  de- 
serving of  attention.  When  the  delivery  of  the  child  is  completed, 
the  OS  uteri  in  general  contracts  more  speedily  than  the  body  of  the 
organ,  and  if  in  this  case  we  endeavour  to  deliver  the  woman  before 
the  fundus  is  prepared  to  overcome  the  resistance  of  the  orifice,  the 
placenta  passes  through  it  with  difiiculty,  which  may  induce  a  belief 
that  it  is  spasmodically  contracted. 

A  bleeding  from  the  arm  where  the  woman  is  strong,  and  there 
are  any  signs  of  irritation  ;  emollient  or  slightly  narcotic  injections;  . 
the  belladonna  ointment,  or  even  a  bath,  if  she  is  very  nervous,  not 
strong,  or  has  a  vivid  sensibility  of  the  sexual  organs,  and  there 
are  any  indications  of  the  approach  of  convulsions  or  flooding; 
patience,  and  gentle  frictions  upon  the  hypogastrium,  should  no  acci- 
dents appear  ;  such  are  the  measures  that  may  be  required  by  such 
a  state  as  we  have  indicated :  it  is  only  when  pressing  and  grave 
circumstances  arise,  that  we  are  allowed  to  introduce  a  finger  into 
the  orifice  to  dilate  it,  while  with  the  other  hand  we  pull  gently  at 
the  cord. 

1 185.  The  encysted  state  of  the  placenta^  which  Solinger  calls 
hernia  of  the  after-birth^  has  not  been  understood  in  the  same  man- 
ner by  the  diflcrent  authors  who  have  spoken  of  it ;  Levret  never 


ENCYSTED  PLACENTA.  539 

saw  but  one  case  of  it,  to  which  he  was  called  by  a  midwife,  who 
supposed  she  was  treating  a  case  of  rupture  of  the  womb.  According 
to  that  author  the  encysted  state  of  the  placenta  is  occasioned  by 
that  portion  of  the  womb  which  corresponds  to  the  placenta  remain- 
ing in  a  state  of  inertia,  whilst  the  other  parts  of  the  organ  contract 
with  more  or  less  force  after  the  birth  of  the  child.  Simson,  on  the 
contrary,  attributes  it  to  the  simple  tendency  of  the  womb  to  recover 
its  primitive  shape,  a  tendency  which  causes  the  internal  orifice  to 
produce,  instantly,  a  real  strangulation,  above  which  is  found  the 
after-birth  enclosed  within  the  cavity  of  the  body,  as  if  it  were  in  a 
small  cell,  while  the  cavity  of  the  cervix  remains  open  below. 
Plessmann  has  reproduced  the  idea  started  by  Levret,  but  he  has 
modified  it :  according  to  his  view  the  womb  must  be  much  more 
highly  irritated  at  those  points  which  press  directly  upon  the  foetus 
than  those  which  only  touch  it  through  the  placenta  during  the 
efforts  of  labour ;  whence  it  follows  that  the  former  contract  sooner 
than  the  latter,  and  the  formation  of  a  separate  sac  for  the  after-birth 
is  very  easy  to  understand.  Peu  seems  to  think  that  the  encysting 
depends  upon  a  peculiar  conformation  of  the  uterus  ;  Leroux  and 
Kok,  that  it  most  frequently  depends  upon  the  rupture  of  the  ner- 
vous filaments,  which  occasions  an  afflux  of  humours,  and,  in  con- 
sequence of  that,  a  spasmodic  contraction  of  some  portions  of  the 
organ.  All  these  explanations  may  be  true  in  some  particular  cases; 
but  Baudelocque  prefers  Simson's  theory  ;  M.  Desormeaux,  resting 
on  a  fact  related  by  Meyeld,  seems  to  be  not  far  from  adopting,  at 
least  in  part,  the  view  taken  of  the  subject  by  Levret  and  Plessmann. 
An  encysted  state  of  the  placenta  is  always  the  result  of  irregular 
contractions  of  the  womb,  after  the  escape  of  the  foetus,  but  I  do 
not  think  that  these  contractions  can  be  explained  upon  the  hypo- 
theses of  Simson,  Levret,  &c.  In  a  woman  to  whom  I  was  called 
by  Madame  Bevalet,  the  internal  orifice  of  the  cervix  offered  but  a 
feeble  resistance,  whereas,  a  little  higher  up,  I  found  a  very  decided 
constriction,  and  after  penetrating  into  a  cavity  situated  to  the  left 
of  the  womb,  in  which  cavity  a  greater  part  of  the  placenta  was 
contained,  I  was  obliged  to  pass  through  another  stricture,  to  get 
to  the  fundus  and  right  side  of  the  organ,  where  the  remain-* 
der  of  the  after-birth  was  retained.  In  another  woman  who 
died  at  the  Hospice  de  UEcole^  I  found  the  uterus  so  mould- 
ed upon  the  placenta,  that  it  was  divided,  as  it  were^  into 
five  shallow  cells,  and  which  evidently  depended  upon  the  pro- 
tuberances formed  by  the  corresponding  cotyledons  of  the  after- 
birth. If  the  placenta  were  solid  and  even,  like  the  head,  the  womb 
in  contracting  would  necessarily  retain  the  form  of  an  ampulla  ;  but 


540  COMPLICATED  DELIVERY  OF  PLACENTA. 

the  cotyledons  in  the  process  of  the  detachment  may  separate  from 
each  other,  and  the  placenta  would  then  offer  more  resistance  in 
some  parts  than  in  others ;  so  that  the  uterus  soon  divides  into 
several  compartments  or  divisions  more  or  less  distinct  from  each 
other,  in  the  same  way  as  it  is  found  to  accommodate  itself  to  the  form 
of  the  head,  of  the  shoulder,  the  breast,  the  pelvis,  and  all  the  pro- 
jecting or  contracted  parts  of  the  foetus,  after  the  liquor  amnii  has 
been  evacuated.  Besides,  what  accoucheur  of  any  experience 
has  not  had  an  opportunity  of  observing,  through  the  abdominal 
parietes,  the  womb  tuberculated,  more  or  less  uneven  or  elongated, 
and  not  always  globular  or  round,  as  it  is  too  generally  said  to  be. 

1 186.  However  it  may  be,  the  cyst  may  be  formed  by  the  fun- 
dus of  the  uterus,  as  supposed  by  Simson  and  Baudelocque,  and 
then  the  organ  approaches  more  or  less  to  the  shape  of  a  calabash ; 
sometimes,  on  the  contrary,  it  is  found  to  be  upon  one  side,  as  was 
observed  by  Levret ;  and,  again,  in  front  or  to  the  rear,  and  at 
points  of  different  height.  Le  Roux  says  that  in  one  instance  the 
placenta  was  encased  in  the  fundus  of  the  womb  like  a  watch-glass 
in  the  lid.  But  such  a  case  has  not  been  noticed  since,  and  there 
ia  every  reason  to  believe  that  the  author  might  have  been  deceived 
by  some  peculiar  circumstances.  M.  Herbin  must  have  been  mis- 
taken also,  when  he  thought  the  after-birth  was  encysted  in  the 
Fallopian  tube,  in  a  woman  whom  he  was  obliged  to  deliver  artifi- 
cially. 

The  placenta,  moreover,  may  be  enclosed  wholly  or  only  partial- 
ly within  the  accidental  cell ;  it  is  sometimes  strangulated  by  the 
circle  of  the  cyst ;  so  that  one  portion  of  it  may  remain  free  in  the 
cervix  while  the  rest  of  it  is  in  some  sort  imprisoned  above,  in  one 
or  more  cells  of  the  body  or  fundus  of  the  womb. 

1187.  To  have  understood  what  has  now  been  said  in  relation  to 
encysted  placenta  is  sufficient  to  enable  one  to  guess  at  the  signs  of  it. 
The  treatment  demanded  by  the  case  differs  accordingly  as  it  is  or 
is  not  accompanied  with  some  complications.  If  there  be  any  com- 
plication, the  contractions  of  the  womb  alone  suffice  to  make  them 
disappear  ;  these  are  to  be  solicited  by  means  of  frictions  upon  the 
hypogastriura,  and  judicious  pulling  at  the  cord.  In  fine,  there 
ought  to  be  no  haste;  we  must  wait.  If  there  is  any  threatening  ap- 
pearance of  hemorrhage,  convulsions,  &c.  or  the  safety  of  the  wo- 
man appears  to  be  in  any  way  compromised,  we  must,  on  the  con- 
trary, make  haste  to  act.  The  fingers  are  to  be  introduced  one 
after  the  other  into  the  mouth  of  the  cyst,  which  is  to  be  dilated 
gently  and  carefully,  and  afterwards  passed  by  the  tohoh  hand  in 
fiearch  of  the  placenta  ;  should  there  be  a  second  opening,  it  is  to 


ENCYSTED  PLACENTA.  541 

be  treated  like  the  first,  and  in  ail  cases  the  cord  is  a  sure  guide  to 
the  after-birth,  which  is  detached  and  separated  by  passing  the 
fingers,  flattened,  between  it  and  the  uterus,  and  which  is  lastly  ex- 
tracted by  pushing  it  with  the  palmar  surface  of  the  hand  down  into 
the  top  of  the  vagina.  Should  the  placenta  be  found  only  partially 
encysted,  we  might,  after  dilating  the  mouth  of  the  cyst,  dispense 
with  going  any  further,  take  hold  of  it  with  the  fingers,  and  immedi- 
ately extract  it.  But  it  is  in  general,  both  a  surer  and  quicker 
method  to  go  into  the  very  cavity  of  the  cyst  itself;  it  being  well 
understood  that,  during  this  operation,  the  hand  that  remains  out- 
side shall  be  employed  in  supporting  the  fundus  of  the  uterus,  in- 
clining it  to  either  side,  and  depressing  it  towards  the  one  that  is 
within  the  organs. 

1 188.  The  rupture  of  the  cord,  in  itself  considered,  does  not  com- 
plicate the  delivery  of  the  placenta  except  by  rendering  the  usual 
tractions  impossible  :  it  may  be  prevented  by  ceasing  to  pull  as  soon 
as  there  is  any  threat  of  its  giving  way  ;  but  it  can  only  be  remedied 
by  going  in  search  of  the  placenta  with  the  hand  ;  and  as  long  as 
there  is  nothing  to  fear  for  the  woman,  this  recourse  is  unndcessary, 
and  we  ought  to  trust  to  the  organism  itself.  It  is  particularly  apt 
to  take  place  when  the  cord  is  inserted  near  the  circumference  of 
the  placenta,  or  when  its  vessels  divide  too  soon,  and  separate  like 
the  rays  of  an  umbrella  upon  reaching  the  placenta.  In  the  first 
case  the  efforts  concentrate  almost  wholly  upon  the  root  of  the 
cord,  which  yields  before  they  can  be  transmitted  to  the  after-birth ; 
in  the  second,  the  vessels  are  weaker  than  if  they  were  united  to- 
gether ;  further,  as  the  force  cannot  act  equally  upon  them  all,  they 
break  very  readily  one  after  the  other. 

1 189.  The  morbid  or  preternatural  adhesion  of  the  placenta  may 
be  either  total  or  partial,  slight  or  intimate.  The  ancients,  Smellie, 
and  others,  refer  it  to  a  scirrhous  state  of  the  womb  or  after-birth  ; 
many  modern  writers  have  preferred  to  attribute  it  to  inflammation. 
But  proofs  are  wanting  on  each  side  of  the  question.  I  have  seen 
the  placenta  hard,  thick,  and  yellowish,  having  lost  its  spongy  ap- 
pearance, sometimes  in  a  few  points,  sometimes  throughout  the 
whole  extent  of  its  uterine  surface  ;  I  have  seen  it  full  of  homogene- 
ous masses,  as  large  as  nuts  or  partridge  eggs,  hard,  and  elastic ; 
but,  in  all  these  cases  the  adhesion,  instead  of  being  stronger,#was 
much  weaker ;  although  rugose  and  tuberculated,  its  surface  was 
smooth,  and  exhibited  no  trace  of  any  laceration.  I  have  also  met 
with  the  yellowish  alteration,  the  placentas  gras  as  they  are  called, 
and  almost  all  the  alterations  pointed  out  by  M.  Brachet  of  Lyons, 
and  M.  Geodrin.     But,  in  common  with  M.  Desormeaux,  I  have 


542  COMPLICATED  DELIVERY  OF  PLACENTA. 

never  observed  any  preternatural  adhesion  to  accompany  them. 
Besides,  I  have  not  found,  by  consulting  the  authors,  that  scirrhus 
has  been  noticed  in  the  womb,  exactly  at  the  place  where  morbid 
adhesions  existed,  and  every  body  knows  that  the  placenta  generally 
contracts  a  less  intimate  union  with  the  fibrous  tumours  on  which  it 
is  sometimes  attached  and  developed,  than  with  the  uterus  itself. 

1190.  As  to  inflammation,  it  may  be  admitted  as  a  probable 
cause,  in  a  certain  number  of  cases  ;  for  example,  when,  in  conse- 
quence of  a  blow  on  the  belly,  a  dull  pain  and  sense  of  heat  are 
found  to  continue  for  several  weeks,  in  the  corresponding  part  of 
the  womb,  and  an  adhesion  of  the  placenta  to  exist  at  the  period  of 
delivery ;  but  these  phenomena  often  continue  during  the  whole 
course  of  a  pregnancy,  without  any  adhesion  taking  place ;  and  in- 
deed adhesions  are  most  frequently  met  with  without  any  such 
precedent  symptoms  having  been  noticed.  Moreover,  it  is  known 
that  the  special  character  of  inflammation  of  the  mucous  membranes 
is,  to  augment  their  secretions,  and  to  terminate  but  very  rarely  in 
adhesion  of  their  surface  to  the  bodies  with  which  they  are  in  con- 
tact. Prudence,  therefore,  requires  that  we  should  wait  for  some 
new  researches,  before  we  pronounce  upon  this  point  of  pathology. 

1191.  When  the  adhesion  is  partial,  it  occupies  sometimes  one 
portion,  and  at  others  the  entire  circumference  of  the  placenta ; 
sometimes,  on  the  contrary,  the  edges  of  the  cake  are  free,  and  it 
adheres  to  the  womb  at  one  or  more  points  of  its  surface  or  at  its 
middle.  When  the  adhesion  is  general,  a  circumstance  but  rarely 
noticed,  but  which  has  notwithstanding  been  seen  by  several  practi- 
tioners, and  particularly  by  M.  Desorraeaux,  it  exhibits  different 
degrees  of  the  affection  like  the  preceding  case.  It  may  in  certain 
cases  be  overcome  by  simply  puHing  at  the  cord,  without  our  being 
obliged  to  enter  the  womb ;  in  other  instances  it  is  so  strong  that 
the  tissues  seem  to*  be  confounded  together,  and  it  is  impossible  to 
overcome  it  without  tearing  the  parts. 

1192.  I  will  not,  with  M.  Desormeaux,  say  that  we  can  recog- 
nize, but  that  we  may  suspect,  or  have  a  right  to  suspect,  the  exist- 
ence of  a  morbid  adhesion  of  the  after-birth,  when,  notwithstanding 
the  repeated  contractions,  hardness,  and  globular  sha^e  of  the  ute- 
rus, we  find  by  passing  the  finger  up  through  the  os  uteri  that  the  pla- 
centt  does  not  present,  and  does  not  yield  to  tractions  suitably  exerted 
upon  the  cord  ;  by  remembering,  besides,  what  has  already  been 
said,  viz.  that  a  morbid  adhesion  is  extremely  rare,  we  ought  to 
avoid  confounding  it  with  the  cases  in  which  the  extraction  of  the 
secundines  is  rendered  difficult  by  some  other  cause. 

1 1 93.  'I'wo  very  diff^erent  modes  of  proceeding  have  been  follow- 


ADHESION  OF  THE  PLACENTA.  543 

ed  by  accoucheurs  in  cases  of  |)athological  adhesion  of  the  placenta  : 
one  party  think  it  ought  to  be  left  wholly  to  the  natural  efforts ;  the 
others,  on  the  contrary,  think  that  we  cannot  too  soon  take  mea- 
sures to  overcome  it.  On  the  one  hand  it  has  been  thought  that,  by 
allowing  the  after-birth  to  remain  for  an  indefinite  period  within  the 
uterus,  we  expose  the  woman  to  the  danger  of  flooding,  or  convul- 
sions ;  that  by  becoming  decomposed,  by  putrefying,  this  substanc? 
must  act  injuriously  upon  the  whole  system,  and  particularly  upon 
the  genital  organs  and  peritoneum,  giving  rise  to  fever  of  a  bad 
character.  On  the  other  hand,  it  is  asserted  that  these  accide;its 
are  far  more  the  effect  of  ill-timed  maneuvres  than  of  the  pro- 
tracted presence  of  the  placenta.  Haller,  Sandifort,  and  M.  de 
Saint-Amand,  have  reported  cases  of  wombs  that  had  been  la- 
cerated, inflamed,  or  gangrened,  in  consequence  of  attempts  to 
break  up  preternatural  adhesions  of  the  placenta  ;  the  after-birth 
has  been  known  to  remain  two,  four,  six,  eight,  fifteen  or  thirty 
days,  or  for  months  together,  within  the  genital  organs,  without 
causing  the  smallest  accident ;  if  it  become  putrid,  the  lochiae  wash 
it  away  piecemeal,  and  its  absorption  may  be  easily  prevented  by 
means  of  injections ;  in  fine,  the  dangers  which,  it  would  seem, 
ought  to  follow  its  forced  detachment,  have  appeared  to  be  much 
greater  than  those  that  might  be  involved  in  its  retention  for  a 
greater  or  smaller  period  of  time. 

i  1 94.  There  is  reason  on  both  sides  of  this  question :  although  it  is 
undeniable  that  the  placenta  may  in  some  cases  remain  for  several  days 
in  the  womb  without  causing  any  accidents,  it  is  very  frequently  the 
cause  of  very  severe  ones.  It  has  a  thousand  times  been  seen  to  carry 
the  woman  to  the  very  brink  of  the  grave,  and  all  the  bad  symptoms 
disappear  as  by  magic,  immediately  upon  its  expulsion  :  were  new 
proofs  of  it  wanting,  i  could  refer  the  reader  to  two  cases  recently 
published  by  M.  Goupil,  and  might  cite  those  that  have  fallen  un- 
der my  own  notice.  As  a  foreign  body,  it  irritates  the  womb,  invites 
the  blood  to  it,  and  is  a  constant  cause  of  floodings,  nervous  affec- 
tions, and  pains  of  all  kinds ;  the  acrimony  which  it  contracts  in 
putrefying,  and  the  odour  which  it  developes,  cannot  be  matters  of 
indiflference  in  a  majority  of  women ;  the  sanies  and  putrescence 
which  result  from  its  decomposition,  will  not  remain  in  contact  with 
the  interior  of  the  womb  without  penetrating,  by  means  of  imbibi- 
tion or  absorption,  in  greater  or  smaller  quantity  into  the  veins  of 
that  organ ;  and  who  will  venture  to  affirm  that  it  would  not  under 
such  circumstances  be  dangerous  ?  Although  it  has  chanced  that 
the  hand  by  being  introduced  within  the  uterus  has  sometimes  lacer- 
ated the  parts  of  the  woman  instead  of  detaching  the  placenta,  it 


544  COMPLICATED  DELIVERY  OF  PLACENTA. 

must  he  attributed  to  a  want  of  skill  in  the  accoucheur,  and  not  to 
the  operation  in  itself  considered  ;  besides,  the  question  is  not 
whether  we  shall  tear  away  or  destroy,  at  all  hazards,  the  intimate 
adhesions  of  the  placenta,  whether  we  shall  peel  it  off  as  the  ancients 
did,  but  merely  whether  we  shall  carefully  separate  it  and  extract  it 
whenever  we  can  do  so  without  lacerating  the  uterus.  Upon  this 
point  I  agree  with  M.  Duchateau,  and  unless  the  child  have  been 
delivered  for  a  long  time,  it  would  be  a  mfstake  to  suppose  that  the 
introduction  of  the  hand  must  be  vpry  painful  and  irritating  to  the 
womb.  Is  it  reasonable  to  fear  any  bad  effects  from  the  gentle  fric- 
tions of  the  fingers,  or  moderate  tractions  exerted  with  the  hand 
upon  an  organ  that  has  been  for  several  hours  contracting  without 
any  inconvenience,  and  with  much  violence  before  ?  Let  me  not 
however  be  understood  as  recommending  here  the  introduction  of 
the  hand  as  soon  as  the  placenta  resists  a  little,  and  that  I  approve 
of  those  who,  by  conforming  to  the  advice  of  Kushler,  never  fail  to 
resort  to  it  with  the  mere  intention  of  removing  coagula  and  other 
substances  that  may  be  contained  within  the  uterus.  My  opinion 
is,  that  we  ought  to  wait  a  few  hours,  and  if  there  be  no  pressing 
haste  from  any  other  cause,  we  may  wait  even  longer,  if  the 
woman  is  of  a  good  constitution  and  has  no  troublesome  disease  of 
any  sort ;  but  in  the  other  circumstances  we  should  act  without 
waiting  too  long. 

1 195.  If  the  cord  remains  whole,  we  should  pull  at  it  in  the  way 
indicated  when  speaking  of  simple  delivery  of  the  placenta ;  when 
the  cord  is  broken,  we  must  attempt  to  hook  a  portion  of  the  placenta 
itself  in  the  fingers.  Levret,  Baudelocque  and  all  the  moderns 
insist  very  much  on  the  necessity  of  drawing  the  cord  down  perpen- 
dicularly to  the  plane  of  the  placenta.  The  following  comparison 
has  been  made  use  of.  If  you  pull  at  a  piece  of  wet  paper  in  a 
direction  parallel  to  the  plane  on  which  it  is  applied,  you  will  not 
detach,  but  you  will  tear  it,  says  Levret;  but  if  you  take  hold  of  one 
of  its  edges  affd  turn  it  up,  you  may  easily  detach  it  without  breaking 
it.  According  to  the  last  named  author  we  must  first  endeavour  to 
ascertain  the  spot  on  which  the  placenta  is  seated,  for  if  it  be  in 
front,  we  shall  make  use  of  the  fingers  arranged  like  a  pulley,  as  has 
been  before  mentioned,  whereas,  if  it  be  situated  on  the  posterior 
part  of  the  womb,  this  pulley  becomes  useless,  and  it  must  be  car- 
ried to  the  right  or  left,  provided  it  be  situated  laterally. 

This  reasoning  would  doubtless  be  very  correct,  provided  we 
were  acting  in  a  free  space,  or  if  the  placenta  were  not  attached  to 
the  walls  of  the  womb  very  much  distended  at  the  time  ;  but  it  seems 
to  be  overlooked,  that  the  fingers  only  support  the  cord  below  the 


COMPLICATED  DELIVERY  OF  PLACENTA.  545 

mouth  of  the  womb  ;  that  the  after-birth  touches  the  womb,  both 
by  its  spongy  and  its  membranous  surface  ;  that,  in  whatever  man- 
ner we  may  take  hold  of  it,  thie  cord  will  always  be  parallel  and 
not  perpendicular  to  the  great  diameter  of  the  womb,  from  its  very 
insertion  till  it  passes  through  the  orifice  of .  the  organ ;  that  by 
pushing  it  strongly  backwards,  in  front,  or  sideways,  as  is  recom- 
mended, we  compel  it  to  rub  and  slide  on  the  corresponding  point 
of  the  OS  uteri  as  on  the  groove  of  a  pulley,  without  in  any  way 
changing  its  relation  of  direction  to  the  placenta  itself.  It  is  as 
well,  therefore,  and  even  better,  to  place  the  three  fingers  in  such 
a  way  that  they  may  act  at  the  same  time  like  a  lever  and  like  a 
pulley,  and  draw  the  cord  and  rest  of  the  after-birth  down  in  the 
longitudinal  axis  of  the  womb ;  but  as  this  axis  may  vary,  may  difier 
more  oi*  less  from  that  of  the  strait,  by  inclining  in  front,  to  the  right 
or  the  left ;  as  it  may  remain  straight,  or  become  curved,  or  even 
zigzag,  according  to  the  position,  form  and  direction  affected  by  the 
womb,  it  will  be  consequently  necessary  to  pull  sometimes  more, 
sometimes  less  towards  the  back  or  side,  as  I  have  already 
shown,  in  speaking  of  cases  of  natural  delivery  of  the  placenta.  It 
is  not  until  we  have  pulled  at  the  cord,  with  all  proper  prudence, 
or  where  the  cord  will  no  longer  bear  the  requisite  force  to  be 
apphed,  that  we  may  proceed  to  enter  the  womb  in  search  of  the 
after-birth.  Provided  the  cord  is  still  not  broken  entirely  off",  we 
make  use  of  it  as  a  guide ;  when  it  is  completely  separated,  the  hand 
will  distinguish  the  placenta  by  its  greater  softness,  its  unevenness, 
if  the  external  surface  be  touched,  and  provided  the  fingers  come  in 
contact  with  its  foetal  surface,  by  its  polished  and  slippery  feel,  and 
the  vascular  ramifications  with  which  it  is  overspread ;  and  in  all 
cases  by  the  less  vivid  sensation  experienced  by  the  woman  when 
the  band  is  pressed  on  it,  than  when  pressed  on  the  womb  itself. 
There  is  generally  no  difficulty  in  this  exploration  for  an  experienced 
person ;  but  by  carelessness  it  would  not  be  impossible  to  mistake 
the  projections,  sometimes  presented  by  the  interior  of  the  womb 
when  it  is  irregularly  contracted,  for  the  reUefs  of  the  placenta,  a 
mistake  which  in  the  hands  of  ignorant  and  unskilful  persons  would 
be  dangerous. 

When  found,  we  should  endeavour  to  get  hold  of  some  point  of 
its  circumference,  if  there  is  one  which  does  not  continue  to  be 
adherent ;  it  is  then  detached  by  turning  it  over  towards  its  mem« 
branous  surface,  or  the  advice  given  by  Baudelocque  may  be  fol- 
lowed :  the  ends  of  the  fingers  flattened  out  may  be  slippe'd  between 
it  and  the  womb ;  then  by  carefully  moving  them  from  side  to  side 
it  may  be  detached  just  as  we  would  separate  two  sheets  of  paper 
3T 


546  DELIVERY  OF  THE  PLACENTA. 

slightly  adhering  together  ;  where  the  adhesion  is  found  to  be  gene- 
ral, the  hand,  disposed  as  before  mentioned,  is  passed  along  the  ex- 
ternal surface  of  some  portion  of  the  membranes,  and  then  gradually 
to  the  circumference  of  the  placenta  ;  when  there,  it  should  act  as 
has  been  described.  Should  the  circumference  alone  have  con- 
tracted morbid  adhesions,  as  seems  to  have  been  noticed  by  Leroux, 
and  the  middle  portion  of  the  cake  be  depressed  by  the  blood,  as 
Baudelocque  states  to  have  happened  under  his  own  observation, 
we  might,  after  the  example  of  that  practitioner,  penetrate  through 
the  placenta,  and  then  proceed  as  in  the  other  cases.  When  its 
separation  is  effected,  the  hand  brings  it  away  by  pushing  it  down 
before  it ;  we  ought  to  take  care  to  leave  no  portion  of  it  behind, 
and  at  the  same  time  remove  all  the  coagula  that  may  be  contained 
in  the  uterus. 

1196.  In  acting  thus,  it  very  rarely  happens  that  the  adhesions 
cannot  be  safely  destroyed.  However,  they  are  sometimes  so  firm 
that  it  is  wholly  impossible  to  make  them  yield.  In  such  a  case,  the 
plan  pursued  by  Smellie,  Levret,  &.c.  should  be  adopted,  namely, 
to  destroy  the  adhesions  wherever  they  are  not  too  firm,  and  tear 
and  bring  away  all  that  we  can  detach,  and  leave  the  remainder  to 
the  natural  powers.  In  peeling  off  the  placenta  we  can  go  no  fur- 
ther than  this,  and  it  would  be  extremely  dangerous  to  persist  in 
endeavouring  to  bring  away  the  whole  of  it,  and  not  leave  the 
smallest  portion  behind  in  the  female  organs. 

1 197.  Sometimes  the  portion  of  the  placenta  which  we  have  been 
unable  to  detach  separates  spontaneously  after  a  (evf  days,  and 
escapes  along  with  the  coagula ;  sometimes  it  becomes  decomposed 
and  comes  away  with  the  lochia  ;  at  others  it  is  not  discharged  for 
a  long  time  ;  Smellie  asserts  that  one  of  his  patients  did  not  expel  it 
until  two  months  had  elapsed,  and  it  was  then  hard  and  quite  dried 
up  i  Kerkring  relates  another  instance  where  it  was  not  passed  away 
till  full  eight  months.  M.  Prost  has  related  two  cases  not  less  re- 
markable :  in  one,  the  after-birth  was  not  expelled  until  the  five 
hundred  and  third  day ;  and  in  the  other,  until  eight  months  and  a 
half  after  the  birth  of  the  child.  Although  its  presence  may  be 
found  not  to  give  rise  to  any  accidents,  some  precautions  ought 
nevertheless  to  be  taken  in  regard  to  it :  for  instance,  the  fingers 
should  from  time  to  time  be  introduced  into  the  vagina  to  ascertain 
whether  it  be  detached,  and  extract  it  as  soon  as  it  tries  to  engage 
within  the  os  uteri ;  in  case  the  fingers  cannot  get  hold  of  it,  recourse 
might  be  had  to  the  pirue  a  faux-germe  of  Levret,  or  to  Dr  Dewees's 
crolchot ;  injections  with  mallows  water,  or  barley  water  sweet- 
ened with  honey,  or  even  with  decoction  of  bark,  may  be  daily 
thrown  into  the  uterine  cavity,  to  cleanse  it,  prevent  absorption. 


COMPLICATED  DELIVERY  OF  PLACENTA.  547 

and  bring  away  the  detritus  of  the  after-birth  as  they  separate  or 
putrefy. 

It  should  not  be  forgotten,  moreover,  that  these  adhesions  are  the 
result  of  a  disease,  and  that  after  their  violent  destruction,  the  inner 
surface  remains  in  a  pathological  state  calculated  to  excite  some  un- 
easiness, and  that  they  leave  behind  them  a  sort  of  suppurating 
wound  that  it  imports  us  to  cleanse  and  heal. 

1198.  Hemorrhage  may  take  place  before  the  delivery  of  the 
placenta,  as  a  complication  of  any  of  the  accidents  heretofore  men- 
tioned ;  but  it  is  also  observed  singly  ;  whether  it  depend  upon  iner- 
tia, spasm,  plethora,  or  irritation  of  the  womb,  it  is  always  a  dan- 
gerous phenomenon,  which  we  ought  to  make  haste  to  combat  ; 
if  the  presence  of  the  placenta  is  not  the  only  cause,  it  at  least  serves 
to  keep  it  up  and  aggravate  it ;  we  should,  therefore,  be  diligent 
in  extracting  it,  even  although  there  should  be  inertia.  Some  au- 
thors, however,  have  thought  that  the  delivery  of  the  placenta  ought 
not  to  be  hurried  while  the  womb  does  not  contract,  unless  there 
should  be  a  partial  detachment  of  the  placenta.  M.  Lacour  has 
lately  endeavoured  to  show,  that  artificial  delivery  of  the  placenta 
can  only  have  the  effect  of  increasing  inertia,  and  consequently  to 
that,  of  producing  flooding ;  but  daily  experience  is  opposed  to  this 
view  of  the  subject,  and  the  contrary  opinion  is  generally  adopted. 
I  have  no  intention  of  repeating  here  what  I  have  already  said 
concerning  the  causes,  signs,  and  general  treatment  of  hemorrhage ; 
but  I  must  speak  of  it  as  one  of  the  complicatioas  of  delivery  of  the 
after-birth. 

1199.  I  am  not  sure  that  its  mechanism  has  been  well  under- 
stood ;  it  is  improperly  attributed  to  the  non-contraction  of  the 
•womb,  in  consequence  of  which  the  blood  must  flow  in  torrents 
from  supposed  orifices  that  remain  gaping  upon  the  internal  surface 
of  the  organ  ;  but  is  it  not  rather  occasioned  by  the  sudden  cessa- 
tion of  pressure  upon  the  hypogastric  vessels,  whereby  the  blood  is 
allowed  to  rush  into  them  with  great  force ;  or  upon  the  circum- 
stance that  the  blood  must  in  some  sort  accumulate  mechanically  in 
the  uterine  vessels,  which  being  no  longer  supported,  pour  it  into 
the  empty  space  which  a  few  moments  before  was  occupied  by  the 
ovum — or  perhaps  on  the  fact,  that  together  with  these  dispositions, 
there  may  be  some  irritating  cause  present  in  the  cavity  of  the  ute- 
rus itself. 

Upon  this  hypothesis,  the  best  means  of  preventing  a  hemorrhage 
would  not  be  to  rub  the  navel  and  the  hypogastrium  with  a  spoonful 
of  brandy  or  cologne  water,  as  advised  by  A.  Leroy,  but  promptly 


548  DELIVERY  OF  THE  PLACENTA. 

to  apply  a  pretty  tight  bandage  to  the  belly,  and  place  the  woman 
with  her  head  very  low  immediately  after  delivery. 

1200.  After  having  extracted  the  placenta,  if  the  flooding  contin- 
ues to  such  a  degree  as  to  excite  apprehensions  relative  to  the  wel- 
fare of  the  patient,  provided  the  womb  remains  soft  and  inactive,  or 
a  sinapism  applied  betwixt  the  shoulders  has  been  tried  in  vain, 
we  may  without  hesitation  introduce  the  hand  into  the  organ.  De 
la  Motte  had  well  remarked  that  this  is  the  most  certain  method  of 
putting  a  stop  to  the  inertia  ;  pressure  made  by  the  hand,  and  in 
Yarious  directions  upon  the  hypogastrium,  which  is  lauded  as  an  im- 
portant discovery  in  the  Journal  des  Savans  of  1722;  can  never  be 
a  complete  substitute  for  this  means  of  relief. 

Injections  of  oxycrate,  of  pure  vinegar  or  iced-water,  which  are 
recommended  by  Saxtorph;  alcohol,  and  sulphuric  or  nitric  acid 
diluted  with  water,  with  which  Pasta  advises  us  to  cauterise  the 
uterine  vessels ;  the  introduction  of  a  hog'a  bladder,  to  be  after- 
wards filled  with  air,  water  or  astringent  fluids,  while  within  the 
womb,  as  proposed  by  MM.  Rouget  and  Vernet,  would  offer 
much  fewor  advantages,  and  expose  the  patient  to  many  more  acci- 
dents, and  are  not  so  easy  of  application  as  the  hand  ;  let  us  add, 
along  with  MM.  Pasteur  and  Evrat,  that  where  we  have  any  fear 
lest  the  hand  alone  should  not  suffice,  we  may  always  introduce, 
along  with  it,  a  peeled  lemon,  or  a  sponge  dipped  in  vinegar. 

1201 .  But  provided  there  should  be  no  inertia,  we  ought  to  have 
recourse  to  the  treatment  indicated  at  the  article  on  hemorrhage  in 
general.,  that  is,  to  revulsives,  refrigerants,  and  even  the  tampon. 
Perhaps  it  would  be  well,  where  the  flooding  is  overwhelming,  to 
compress  the  aorta  above  the  sacro- vertebral  angle,  while  waiting 
until  other  mea.surcs  might  be  put  in  practice ;  immediately  after 
the  birth  of  the  child,  the  abdominal  parietes  are  soft,  and  in  many 
women  it  would  not  be  difficult  to  act  upon  the  aorta  with  the  thumbs ; 
so  that  without  attaching  so  much  importance  to  this  measure, 
which  has  already  been  spoken  of  by  Boer,  Madame  Lachapelle, 
M.  Duges,  &.C.  as  is  attributed  to  it  by  MM.  Trahon  and  Bau- 
^lelocqiie,  Jun.,  I  would  willingly  have  recourse  to  it,  should  an. 
occasion  present. 

1202.  The  ergot  of  rye,  employed  by  MM.  Balardini,  Biges- 
chi,  Bordoi,  Goupil,  Villeneuve,  &c.  is  said  to  put  a  stop  to  iner- 
tia, to  compel  the  womb  to  contract,  and  thus  overcome  the 
adhesions  of  the  after-birth,  expel  the  placenta,  and  tberel>y  suspend 
the  flooding.  According  to  those  practitioners,  as  the  delivery  of 
the  pinrenta  hae?  been  always  found  to  be  prompt,  and  never  accom- 


COMPLICATED  DELIVERY  OF  PLACENTA.  549 

panied  or  followed  by  hemorrhage  in  women  who  have  taken  the 
oxytocic  powder  during  labour,  we  ought  to  conclude  that  it  must 
be  of  great  service  in  cases  of  preternatural  adhesion  of  the  placenta, 
and  flooding  coming  on  after  the  birth  of  the  child. 

I  would  willingly  exhibit  the  article  in  cases  of  adhesion,  but  hav- 
ing bad  no  opportunities  of  meeting  with  them,  I  am  not  in  posses- 
sion of  any  facts  of  my  own  in  relation  to  it.  As  to  hemorrhage, 
some  physicians  have  thought  that  they  have  seen  it  produced  by 
the  obstetrical  powder ;  a  young  woman  was  seized  with  a  violent 
flooding  after  the  birth  of  the  child,  although  I  had  administered  to 
her  a  dose  consisting  of  forty-five  grains  of  ergot,  during  the  labour, 
and  notwithstanding  it  had  produced  all  the  efiect  I  had  anticipated. 
I  have  also  observed  a  very  similar  case  quite  recently,  and  am  led 
to  believe  that  although  the  ergot  may  be  useful  where  the  flooding 
is  produced  by  inertia  of  the  womb,  it  might  very  well  be  injurious 
in  the  other  cases,  which  are  far  more  numerous  than  is  generally 
supposed. 

1203.  Another  resource,  which  was  first  put  in  practice  by  Doc- 
tor Mojon,  then  by  MM.  Hoffmann,  Taroni,  Lemaistre,  &c.  con- 
sists in  injecting  a  cold  styptic  fluid  into  the  placenta,  through  the 
umbilical  vein.  M.  Mojon  insists  that  previously  to  throwing  in  the 
injection,  we  should  draw  the  blood  out  of  the  vein  and  its  branches 
by  exhausting  with  the  syringe ;  but  MM.  Hoffrnann  and  Taroni 
have  succeeded  without  using  this  precaution  ;  the  first  made  use  of 
the  oxicrate  ;  the  second  employed  brandy  and  water  ;  and  the  last 
named  practitioner  was  satisfied  with  injecting  cold  water  alone.  In 
all  three  of  the  cases,  the  womb,  which  had  previously  been  soft  and 
inert,  contracted  immediately  ;  the  placenta  was  expelled,  and  the 
hemorrhage  was  arrested  ;  but  nothing,  not  even  the  fact  recently 
related  by  M.  Sandras,  proves  that  the  placenta  was  still  adherent, 
and  that  more  skilful  tractions  exerted  upon  the  cord  might  not 
have  produced  the  same  effect ;  a  case  related  a  few  days  ago  in  a 
public  journal  would  even  prove,  were  the  journal  and  the  author 
worthy  of  credence,  that  these  injections  may  be  wholly  inefficacious. 

1204.  This  remedy  might  be  tried  in  a  case  of  supposed  ad- 
hesion, with  inertia  and  flooding,  after  having  vainly  employed  the 
ordinary  resources,  and  previously  to  introducing  the  hand  into  the 
uterus.  Its  action  must  be  both  mechanical  and  chemical  ;  it  un- 
wrinkles  and  swells  the  placenta,  distends  the  womb,  and  oc- 
casions a  sudden  reduction  of  temperature,  a  contraction  of 
the  vascular  mouths,  and  a  more  or  less  powerful  constriction, 
admitting,  always,  that  the  fluid  injected  reaches  as  far  as  the 
uterine  surface  of  the  placenta.     It  must  in  fact  combine  a  part 


550  DELIVERY  OF  THE  PLACENTA. 

of  the  advantages  attributed  by  certain  authors  to  injections  thrown 
directly  into  the  womb,  or  through  bladders,  and  to  the  tampon,  so 
much  lauded  by  Leroux,  without  having  any  of  the  inconveniences. 

1205.  The  operation  is,  besides,  very  simple :  after  having  dis- 
engaged the  cord,  the  pipe  of  a  syringe  containing  six  or  eight 
ounces  of  very  weak  brandy  and  water,  vinegar  and  water,  or  any 
suitable  medicinal  liquid,  may  be  introduced  into  the  vein  ;  the  in- 
jection may  be  pushed  up  with  sufficient  force  to  make  it  penetrate 
throughout  the  placenta,  and,  to  hinder  it  from  escaping  before  it 
has  produced  its  effect,  a  ligature  must  be  thrown  round  the  cord. 
The  woman  is  soon  seized  with  tenesmus  and  colic  ;  the  uterus  and 
abdominal  muscles  contract ;  the  os  uteri  yields,  and  the  after- 
birth is  promptly  expelled.  M.  Guillon  recommends  that  instead 
of  all  these  means,  we  should  inject  some  bouillie,  a  sort  of  liquid 
cataplasm,  astringent,  or  emollient  into  the  interior  of  the  womb 
itself,  and  I  see  not  why  we  might  not  follow  his  example  where  the 
intervention  of  the  hand  is  not  allowable. 

1206.  Convulsions.,  and  repeated  fits  of  syncope  which  come  on 
after  the  birth  of  the  child,  may,  like  flooding,  be  occasioned  by  va- 
rious causes  ;  but  the  presence  of  the  after-birth,  being  of  itself 
sometimes  sufficient  to  produce  them,  we  should  begin  by  delivering 
it  in  women  so  affected.  For  the  remainder,  we  are  to  act  as  has 
been  advised  in  speaking  of  convulsions  in  general.  The  same  is 
true  of  the  simple  debility  or  exhaustion  that  sometimes  supervene 
upon  a  protracted  labour,  or  succeed  to  other  accidents.  Provided 
the  after-birth  seems  to  have  any  influence  in  occasioning  this  state, 
we  should  make  haste  to  extract  it ;  nothing  but  the  necessity  of 
leaving  the  woman  in  a  state  of  quiet,  or  the  fear  of  bringing  back 
a  flooding,  should  induce  us  to  temporise,  in  a  case  where  no  other 
accident  was  at  the  moment  present. 

1207.  In  twin  pregnancy  the  delivery  of  the  placenta  ought  not 
to  be  solicited  until  after  the  complete  termination  of  the  child- 
birth. As  the  appendages  of  the  two  children  always  adhere  to- 
gether, at  least  by  some  of  their  points,  the  one  could  not  be  ex- 
tracted without  detaching  the  other,  not  that  this  practice  must  in- 
evitably occasion  an  inertia  of  the  womb  or  bring  on  flooding,  as 
has  been  supposed  by  some  persons,  who  found  the  opinion  upon 
the  false  notion  that  certain  large  orifices  would  remain,  through 
which  the  blood  flows  into  the  uterine  cavity,  but  because  it  is  al- 
ways dangerous  to  destroy  the  organic  relation  of  the  foetus  with  its 
motiier,  unless  it  be  on  the  point  of  expulsion  itself  One  single 
circumstance  might  permit  us  to  depart  from  this  rule  :  it  is  when 
the  after-birth  of  the  first  child  presents  spontaneously  at  the  orifice. 


COMPLICATED  DELIVERY  OF  PLACENTA.  551 

before  the  birth  of  the  second,  and  then  care  should  be  taken  not  to 
destroy  the  adhesions  of  the  one  that  remains. 

In  general,  the  delivery  of  the  placenta  afler  the  birth  of  twins, 
is  longer  in  taking  place  than  in  the  common  case,  provided  it  be 
not  provoked  by  the  accoucheur  ;  which  depends  upon  the  uterus 
having  rather  less  tendency  to  contract,  and  perhaps  also,  upon  the 
fact  that  the  size  of  a  double  placenta,  is  necessarily  greater. 

In  order  to  assist  it,  we  may  take  hold  of  one  of  the  cords,  or 
one  of  the  placentae,  and  draw  down  the  two  after-births,  one  after 
the  other  ;  but  it  is  better,  more  prompt,  and  safer  to  twist  the  two 
cords  round  each  other,  so  as  to  make  one  string  of  them,  and  then 
act  as  in  a  simple  case.  The  placentae,  being  almost  never  at  the  same 
level  in  the  organs,  present  at  the  orifice  in  succession,  and  not 
both  at  once  ;  besides,  if  the  contrary  should  happen  to  be  the  case, 
and  their  escape  rendered  difficult,  it  would  be  too  easy  to  over- 
come such  an  inconvenience  for  it  to  be  necessary  for  me  to  enter 
into  any  long  explanations  concerning  it. 

1208.  After  an  abortion^  the  delivery  of  the  placenta  is  generally 
not  so  easy  as  it  is  after  a  labour  at  full  term  ;  in  the  three  first 
months  of  pregnancy  the  ovum  is  almost  always  expelled  whole,  and 
there  is  therefore  no  delivery,  properly  so  called ;  but  after  that 
period,  this  expulsion  in  mass  becomes  more  and  more  rare  and  dif- 
ficult. TJie  foetus  escapes  first ;  its  involucra  remain  and  are  not 
expelled  until  sometime  afterwards,  sooner  or  later.  The  cervix 
recovering  its  original  form  and  length,  soon  resists  the  necessarily 
feeble  eftbrts  of  the  uterus ;  the  after-birth  having  scarcely  changed 
its  relations  to  the  organs  ip  which  it  is  contained,  cannot  clear  its 
orifice  and  fall  into  the  vagina,  but  with  great  difficulty.  On  the 
other  hand,  the  cord  is  so  weak  that  it  null  bear  only  shght  pulling, 
and  notwithstanding,  retention  of  the  placenta  after  abortion  is 
scarcely  a  less  serious  matter  than  after  labour  at  full  term. 

As  inertia,  and  inversion  of  the  womb  are  not  to  be  dreaded  in 
this  case,  the  wisest  course  in  my  opinion  is  to  make  haste  to  effect 
delivery  before  the  cervix  has  had  time  to  close,  either  by  pulling 
moderately  at  the  cord,  or  by  getting  hold  of  the  placenta  with  the 
fingers  if  possible.  But  when  we  have  waited  too  long,  or  have 
been  called  too  late,  we  are  compelled  to  wait  still  longer,  and  confine 
ourselves  to  endeavours  to  promote  the  contraction  of  the  uterus. 
Should  any  accidents  supervene,  the  hand  could  not  be  carried  up  as 
far  as  the  placenta,  on  account  of  the  resistance  of  the  cervix,  and 
the  smallest  extractive  force  would  soon  rupture  the  cord.  I  pre- 
sume this  would  be  the  proper  case  to  try  the  injections  recom- 
mended by  Dr  Mojon.  If,  however,  the  placenta  should  appear  at 
the  orifice,  or  could  be  felt  with  the  finger,  and  the  tractions  or  the 


552  DELIVERY  OF  THE  PLACENTA. 

hand  should  prove  insufficient  to  extract  it,  an  attempt  might  still  be 
made  to  bring  it  down  with  the  pince  a  faux  germes.  Otherwise, 
its  expulsion  is  to  be  left  to  the  natural  powers,  and  we  must  take 
care  to  prevent  the  occurrence  of  accidents,  or  if  they  do  occur,  to 
combat  them  as  soon  as  they  make  their  appearance.  We  may  re- 
sort to  blood-letting,  opiates,  and  baths,  general  and  local ;  emollient 
or  detergent  injections  are  thrown  into  the  vagina,  and  even  into 
the  womb,  so  as  to  neutralise  the  effects  of  putrefaction;  the  woman 
is  confined  to  a  strict  diet,  and  as  soon  as  the  os  uteri  becomes  some- 
what open,  such  portions  of  the  after-birth  as  may  present  themselves 
are  to  be  removed. 

Sometimes  all  these  precautions  are  of  no  avail,  provided  the  os 
uteri  has  closed  soon  after  the  escape  of  the  foetus,  and  the  placenta 
may  remain  in  the  uterus  for  a  longer  or  shorter  period  without 
putrefying  ;  cases  have  been  seen  whe're  the  women  in  some  sort 
forgot  it,  did  not  discharge  it  until  after  the  lapse  of  one  or  two  years, 
when  they  even  became  impregnated  again,  proceeded  to  their  full 
term,  and  then  discharged  it  together  with  the  new  placenta.  But 
the  placenta  and  membranes  are  most  commonly  expelled  either 
piecemeal  or  in  one  mass,  in  the  course  of  the  first  week  after  the 
miscarriage,  or  they  are  gradually  discharged  along  with  the  lochia, 
or  by  means  of  injections.  It  will  be  understood,  further,  that  these 
difficulties  become  more  frequent  and  numerous  in  proportion  as 
the  abortion  takes  place  nearer  to  the  middle  period  of  gestation  ; 
that  they  are,  on  the  contrary,  less  severe,  and  more  easy  to  over- 
come, the  nearer  they  occur  to  the  natural  period  of  parturition. 


ARTICLE  11. 

Management  of  the  Child. 

The  management  of  the  child  varies  according  to  the  state  iq 
which  it  happens  to  be  at  birth,  and  accordingly  as  it  is  healthy  or 
in  a  diseased  state. 

SECTION  1. 

Cf  the  FcBtus  in  a  Healthy  State. 

When  the  child  is  born  alive  and  in  good  health,  which  is  known 
by  its  cries  and  movements,  af\er  placing  it  properly  between  the 


MANAGEMENT  OF  THE  CORD.  553 

mother's  limbs,  the  cord  is  the  only  thing   that  requires   the  ac- 
coucher's  attention  at  first. 

As  soon  as  the  child  passes  from  the  vulva,  it  should  be  laid 
crosswise,  upon  its  side,  with  the  face  turned  towards  the  foot  of  the 
bed,  between  the  woman's  thighs.  In  this  situation  it  can  breathe . 
and  run  no  risk  of  being  suffocated  by  the  matters  flowing  from  the 
vagina.  Should  the  cord  be  found  coiled  round  the  body,  it  must  be 
disengaged  ;  it  should  be  freed  from  any  portions  of  the  membranes 
that  it  may  have  brought  along  with  it,  and  also  from  the  mucous 
which  sometimes  obstruct  the  mouth  or  throat ;  and  lastly,  we 
proceed  to  tie  and  cut  the  umbilical  cord. 


SECTION  II. 
On  Tying  and  Cutting  the  Cord. 

1209.  In  the  time  of  Hippocrates  the  cord  was  not  cut  until  the 
placenta  was  delivered.  If  the  placenta  was  slow  in  coming  away, 
the  child  was  placed  upon  a  pile  of  wool,  or  on  a  leather  bottle  with 
a  small  hole  in  it,  so  that  by  the  gradual  subsidence  of  the  skin  or 
pile  of  wool,  the  weight  of  the  child  might  react  by  almost  insensi- 
ble degrees  upon  the  placenta,  and  extract  it  without  any  kind  of 
violence.  Deventer  thinks  the  placenta  should  be  extracted  pre- 
viously to  dividing  the  cord  ;  Dionis  followed  sometimes  one  plan, 
sometimes  another.  Where  the  secundines  required  only  gentle 
pulling  to  extract  them,  he  did  not  cut  the  cord  until  after  they 
came  away,  and  pursued  an  opposite  practice  when  he  found  it 
necessary  to  introduce  the  hand  in  search  of  the  after-birth.  Since 
the  time  of  Levret  it  has  been  established  as  a  general  rule,  among 
accoucheurs,  to  separate  the  child  from  the  mother  as  soon  as  it  has 
passed  through  the  vulva,  and  that  it  is  never  necessary  to  wait  for 
the  expulsion  of  the  fcetal  appendages.  At  first  view  the  conduct 
of  the  ancients  appear  to  be  more  rational,  and  more  physiological 
than  that  of  the  moderns  ;  it  seems  that  the  placenta  ought  immedi- 
ately to  follow  the  foetus,  or  at  least  be  separated  from  the  uterus 
before  the  cord  can  be  prudently  cut;  that  before  it  is  divided,  the 
circulation  ought  to  be  permitted  gradually  to  take  on  its  new  type, 
which  soon  becomes  similar  to  that  of  the  adult;  but  in  reality  it  is 
not  perceived  that  the  present  mode  of  practice  produces  the  least 
inconvenience  to  the  fcetus,  and  is  certainly  better  for  the  mother. 
It  would  be  in  vain  to  object  that  this  conduct  is  not  natural,  for  it 
is  followed  by  most  of  the  animals  themselves,  who  tear  oflTthe  um- 
bilical  cords  of  their  young  as  they  escape  from  the  vulva.     Not 

'         3   U 


554  MANAGEMENT  OF  THE  CHILD. 

only  should  we  not  wait  until  the  placenta  is  delivered,  but  it  is  of 
no  use  to  wait  until  the  pulsations  have  ceased,  before  we  cut  the 
cord,  as  recommended  by  Denman  and  A.  Leroy.  Neither  is  there 
a  general  agreement  as  to  whether  the  cord  should  be  cut  or  tied  firat. 

12 10.  If  we  begin  by  applying  the  ligature,  we  have  to  do  it 
under  the  bedclothes ;  and  on  the  lying-in  bed,  it  is  not  so  easy  to 
examine  the  umbilicus,  and  we  deprive  ourselves  of  the  advantage 
of  disengorging  the  viscera  of  the  blood  with  which  they  are  some- 
times overloaded.  In  fine,  as  soon  as  respiration  is  established,  the 
placental  circulation  becomes  completely  useless.  If  we  cut  the 
cord  before  we  tie  it,  we  are  at  liberty  to  carry  the  fcetus  to  any 
convenient  place,  attend  to  it  if  it  be  not  well,  and  examine  it  with 
all  desirable  attention.  However,  it  must  be  confessed  that  if  the 
child  present  nothing  peculiar  as  to  itS|  condition,  one  of  these 
modes  of  proceeding  is  scarcely  preferable  to  the  other,  and  that  each 
practitioner  is  at  liberty  to  adopt  the  one  that  pleases  him  best,  with- 
out its  having  any  influence  upon  the  result  of  his  practice. 

1211.  The  place  where  the  cord  is  to  be  divided  is  altogether  a 
matter  of  choice.  If  it  be  cut  at  the  distance  of  four  or  five  inches 
from  the  navel  instead  of  nearer  to  or  farther  from  the  placenta,  it  is 
done  in  order  that  what  is  left  of  the  cord  may  not  be  troublesome 
by  its  quantity,  and  may  admit  of  the  ligature  being  applied  at  a  cer- 
tain distance  from  the  abdomen.  Any  cutting  instrument  may  be 
made  use  of,  and  the  scissors  are  used  only  because  they  arc  rather 
more  convenient  than  a  bistoury.  Although  a  rusty  instrument  can 
not  possibly  occasion  any  redoubtable  accident,  such  as  tetanus,  as 
A.  Leroy  supposed,  it  is  nevertheless  best  to  make  use  of  such  only 
in  cases  where  sharper  ones  cannot  be  obtained;  on  the  other  hand, 
there  could  be  no  advantage,  obtained  by  tearing  off",  bruising,  or 
sawing  of  the  cord,  as  some  authors  have  recommended,  with  the 
view  of  more  closely  imitating  the  quadrupeds,  even  although  we 
intend  to  dispense  with  the  use  of  a  ligature. 

1212.  The  cord  being  cut,  it  should  be  squeezed  between  the 
fore  finger  and  thumb,  if  there  should  be  any  disposition  in  it  to 
bleed  ;  the  other  three  fingers  take  hold  of  the  breech;  the  other  hand 
is  placed  under  the  shoulders  and  nape  of  the  child's  neck,  which  is 
thus  removed  from  the  lying-in  bed,  and  commonly  deposited  on  the 
nurse's  lap;  there  it  can  be  examined  at  leisure.  Previously  to  put- 
ting on  the  ligature,  we  ascertain  that  no  loop  of  intestine  has  got  out 
through  the  uml»ilicus,that  there  is  not  an  omphalocele.  Should  such 
a  tumour  exist,  wq  ought  to  try  to  reduce  it,  or  at  least  not  to  include 
it  within  the  ligature  we  are  about  to  place  on  the  cord,  as  happen- 
ed to  some  children  under  the  notice  of  M.  Sabaticr  and   Madame 


MANAGEMENT  OF  THE  CORD.  555 

Boivin.  In  the  time  of  Aristotle  the  midwives  were  in  the  liabit  of 
forcing  the  blood  contained  in  the  cord  into  the  belly  of  the  foetus 
before  they  tied  it,  and  pretended  by  means  of  this  practice,  which 
has  been  revived  at  the  commencement  of  t!ie  present  century,  to 
restore  strength  and  vigour  to  feeble  children.  Some  again  have 
maintained,  along  with  Rhazes  and  the  other  Arabian  physicians, 
the  Abbe  Bizance  and  M.  Sarton,  that  this  blood  ought  to  be  very 
carefully  squeezed  out  instead  of  forcing  it  in;  tliat  it  is  particularly 
necessary  to  evacuate  the  kind  of  serosity  or  lymph,  more  or  less 
of  which  is  contained  in  the  cord,  either  by  covering  it  with  punc- 
tures, or  squeezing  it  with  the  fingers,  either  naked  or  covered  with 
a  piece  of  rag,  for  they  attributed  to  the  retention  of  these  matters 
the  property  <^  producing  the  small  pox,  crusts  on  the  head, 
tetanus,  and  convulsions.  Levret,  also,  thinks  that  by  squeezing  out 
these  humours  we  may  prevent  the  occurrence  of  infantile  jaundice, 
that  at  least  which  he  compares  to  ecchymosis  ;  but  this  opinion, 
which  M.  Desormeaux  seems  to  partake  in  some  measure,  cannot 
be  maintained,  and  scarcely  deserves  to  be  discussed. 

In  my  opinion  it  is  of  very  little  consequence  whether  we  take  this 
precaution  or  omit  it :  if  it  is  sometimes  of  use,  it  is  so  because  it 
admits  of  the  ligature  being  applied  upon  the  vessels  more  exactly, 
without  its  being  so  easy  to  cut  them  off,  and  admits  of  their  drying 
sooner,  and  without  putrefaction. 

1213.  As  to  the  ligature  itself,  De  la  Motte  advises  us  to  apply  it 
at  the  distance  of  one  inch,  Deventer,  Levret,  and  the  moderns  at 
the  distance  of  two  fingers  breadth,  others  at  three,  four,  five,  six, 
and  even  twelve  inches  fi-om  the  abdomen.  Some  persons  have  re- 
commended the  application  of  two,  and  in  such  a  way  that  the  one 
nearest  the  abdomen  should  not  be  so  tight  as  the  otiier.  Some- 
times it  has  been  recommended  to  draw  it  very  tightly,  at  otliers 
very  loosely.  One  person  is  content  with  a  single  turn  and  a  single 
knot;  another  thinks  there  should  be  two  turns  and  a  double  knot; 
a  third,  like  Plenck  and  M.  Desormeaux,  makes  first  one  turn  and 
one  knot  and  then  bends  the  cord  into  a  noose  to  tie  another  knot 
upon  it.  Some  would  not  dare  to  use  any  thing  except  tape,  whereas 
wiser  persons  make  use  of  what  they  can  find  at  hand  ;  but  in  fact, 
is  this  ligature  really  necessary  ? 

No  animal  can  have  recourse  to  it.  At  the  period  of  the  con- 
quest of  Brazil  travellers  reported  that  the  aborigines  merely  chewed 
or  tore  off  the  cord  with  their  teeth,  and  that  they  did  not  tie  it  up. 
If  a  careful  attention  be  paid  to  what  happens  after  an  ordinary  birth, 
it  will  be  seen  that  the  pulsations  grow  weaker,  and  soon  disappear 
in  the  cord,  beginning  at  the  placenta,  and  that  af\er  a  few  minutes 


556  MANAGEMENT  OF  THE  CHILD, 

it  may  be  cut  without  being  followed  by  the  least  hemorrhage. 
This  remarkable  phenomenon,  which  is  attributed  to  the  change  of 
direction  of  the  iliac  arteries,  and  to  the  difficulty  experienced  by  the 
blood  in  passing  into  the  aorta  through  the  ductus  arteriosus^  and 
into  the  cord  through  the  umbilical  arteries,  always  takes  place 
where  every  thing  occurs  in  a  natural  and  regular  order,  but  in  re- 
ality depends  upon  the  circumstance  that  the  attractive  force  exerted 
by  the  placenta  upon  the  blood,  is  replaced  by  that  of  the  respira- 
tory organ  ;  and  that  the  after-birth  is  no  longer  any  thing  more 
than  an  inert  substance,  without  vitality,  which  is  abandoned  by  the 
blood,  as  it  abandons  a  gangrenous  or  asphyxiated  limb. 

It  is  so  independent  of  any  mechanical  change  in  the  arrangement 
of  the  vessels,  that  if,  as  was  done  by  Vesalius,  the  belly  of  an  ani- 
mal at  the  full  term  of  gestation  be  opened,  the  pulsations  of  the 
cord  are  seen  to  continue  as  long  as  the  foetus  continues  to  live 
without  respiring,  and,  on  the  contrary,  to  cease  as  soon  as  the  air 
enters  freely  into  the  lungs.  Beclard  has  seen  the  same  thing  in  the 
dog.  I  offte  received  a  human  fcetus,  at  the  sixth  month  of  preg- 
nancy, enclosed  within  its  membranes.  The  umbilical  arteries  con- 
tinued to  beat  strongly  as  long  as  the  membranes  were  unruptured  ; 
but  they  fell  into  inertia  as  soon  as  the  lungs  and  chest,  upon  coming 
in  contact  with  the  air,  attempted  to  perform  some  respiratory 
movements.  And  do  we  not  every  day  see  the  blood  flow  or  stop 
spontaneously  in  the  same  child,  accordingly  as  the  respiration  is 
free  or  embarrassed  ? 

1214.  Whatever  may  be  the  fate  of  the  explanation,  it  is  not  the 
less  true,  that  if  the  cord  were  left  to  itself  without  any  ligature,  it 
would  not  expose  the  foetus  to  any  hemorrhage,  or  any  accident, 
even  although  it  should  be  cut  oft"  clean,  and  not  contused  or  torn. 
However,  as  the  contrary  may  happen,  as  a  mere  compression  of 
the  chest,  or  an  embarrassed  state  of  the  function  of  any  organ  suf- 
fices to  disorder  the  general  circulation  and  enable  the  blood  again 
to  pass  through  the  umbilical  ring  ;  as  cases  are  reported  of  children 
who  have  died  from  bleeding  in  consequence  of  the  cord  being  not 
well  secured ;  and  lastly,  as  there  is  no  danger  occasioned  by  the 
application  of  a  ligature,  as  it  presents  no  difficulty,  we  are  not  au- 
thorised to  dispense  with  it ;  we  should  even  be  culpable  to  neglect 
it.  Although  the  observations  of  Fautoni  and  Schultz,  prove  that  it 
is  not  indispensable,  those  of  Daniel  prove  that  it  would  not  always 
be  safe  to  omit  it  even  after  a  rupture  of  the  cord  ;  and  the  cautery, 
made  use  of  in  Turkey,  will  always  be  less  safe  and  more  trouble- 
some. 

Further,  whether  tied  or  not,  the  cord  constantly  separates  from  the 


MANAGEMENT  OF  THE  CORD.  557 

abdomen  at  the  same  place,  that  is  to  say,  at  the  spot  where  it  joins 
the  skin,  and  consequently,  a  few  lines  beyond  the  surface  of  the 
belly  ;  and  I  do  not  think  it  my  duty  to  combat  the  old  women's  no- 
tion, which  was  derived  from  the  physiology  of  the  ancients,  and 
which  requires  that  the  cord  should  be  cut  very  near  the  umbilicus 
if  the  child  is  a  girl,  and  very  far  from  the  abdomen  if  it  is  a  boy, 
such  a  mode  of  cutting  it  being  supposed  to  exert  a  great  influence 
upon  the  development  of  the  organs  of  copulation  ! 

1215.  I  always  make  one  turn  of  the  ligature,  which  I  tie  with  a 
single  knot,  sufficiently  hard  to  close  the  vessels  ;  I  then  carry  the 
two  ends  behind,  cross  them,  and  bring  them  back  again  in 
front,  where  they  are  secured  by  a  double  knot  which  is  tied  some- 
what more  firmly.  I  pursue  this  method  because  it  is  very  simple, 
and  because  I  have  never  seen  it  followed  by  any  accident.  But  if 
the  cord  were  a  very  large  one,  I  would  willingly,  for  the  sake  of 
greater  security,  imitate  the  conduct  of  M.  Desormeaux  and  Plenck, 
that  is  to  say,  that  after  tying  the  first  knot,  I  would  make  a  loop  of 
the  cord,  and  secure  it  in  the  second  turn  of  the  ligature.  Besides 
this  ligature,  some  practitioners  apply  one  to  the  placental  end  of  the 
cord,  to  prevent,  as  they  say,  any  hemorrhage  from  taking  place 
from  the  woman.  But  what  I  have  said  concerning  the  utero-pla- 
cental  vascular  system,  proves  that  this  is  an  unnecessary  precau- 
tion. It  can  be  of  no  use  except  in  twin  cases,  and  even  there,  to 
make  it  necessary,  the  vessels  of  one  placenta  ought  to  communi- 
cate directly  with  those  of  the  other,  as  appears  to  have  been  the 
case  in  two  instances  met  with  by  M.  Mancel,  but  which  must  be  a 
very  rare  occurrence. 

§.  II.  Of  cleansing  the  child. 

1216.  Without  undertaking  to  decide  whether  our  first  parents 
took  the  trouble  of  removing  the  unctuous  matter  which  covers  and 
soils  the  skin  of  the  fcetus  at  birth ;  without  recurring  to  the  question 
whether,  as  is  supposed  by  M.  Richerand  and  most  of  the  modern 
physiologists,  this  substance  is  a  mere  result  of  the  sebaceous  secre- 
tion, rather  than  a  deposit  of  some  principle  contained  in  the  liquor 
amnii,  as  is  supposed  by  the  chemical  physicians  in  accordance 
with  the  sentiments  of  M.  Vauquelin,  I  v/ill  say,  notwithstanding 
the  ideas  of  Gaultier'  de  Claubry,  that  none  but  beneficial  effects 
can  follow  its  removal.  If  it  were  the  intention  of  nature  to  retain 
it  upon  the  surface,  why  would  the  goat,  the  cow,  and  so  many 
other  animals  lick  their  young  so  carefully  and  sometimes  so  rudely 
as  soon  as  they  are  born  ?  I  know  that  no  very  serious  inconve- 
nience would  follow  should  it  be  left  adhering  to  the  surface,  and 


558  MANAGEMENT  OF  THE  CHILD. 

that  it  would  come  off  in  a  few  days  by  sticking  to  the  clothes,  or 
with  the  epidernriis  to  wliici;  it  adheres,  and  which  always  desqua- 
mates within  tlie  first  few  weeks ;  lastly,  i  do  not  believe  its  presence 
can  have  any  great  influence  in  producing  scabs  on  the  head,  of 
crusta  lactea  of  the  iiead  in  children  at  the  breast,  or  crusts  on  other 
parts  of  the  body  ;  nor,  consequently,  that  it  is  absolutely  necessary 
to  remove  it  with  scrupulous  minuteness,  even  to  the  very  smallest 
portion ;  but  I  think  that  none  of  it  ought  to  be  left  except  in  cer- 
tain spots  from  which  it  cannot  be  "readily  got  off. 

Where  nothing  is  made  use  of  but  a  napkin  to  wipe  it  off,  some 
portions  always  remain  adhering  to  the  skin,  unless  it  is  rubbed  so 
long  and  so  violently  as  to  be  sometimes  dangerous ;  nor  can  we 
succeed  much  better  by  immersing  the  fcetus  in  a  warm  bath,  unless 
it  be  composed  of  a  mucilaginous  or  saponaceous  fluid. 

It  should  be  first  diluted  and  thinned  with  a  little  fresh  butter  or  oil, 
mucilage,  or  any  kind  of  grease,  or  what  is  still  better,  the  yelk  of  an 
egg,  which  renders  it  miscible  with  water.  A  weak  solution  of  soap 
and  water  might  also  be  made  use  of  very  properly,  but  the  other  sub- 
stances are  preferable.  This  ceruminous  substance  is  met  with  in 
greatest  abundance  at  the  principal  bends  of  the  limbs,  and  on  the 
head  and  neck  :  when  it  is  well  detached  from  the  body,  it  should 
be  gently  wiped  with  a  dry  napkin  ;  after  which,  in  order  to  finish 
the  cleansing  of  the  child,  we  may  first  merely  rub  its  skin  with  a 
soft  sponge  dipped  in  warm  water,  or  weak  wine  and  water,  and 
then  again  with  the  sponge  squeezed  dry,  to  clean  off  any  blood  or 
other  matter  adhering  to  it. 

Some  persons  think  the  whole  child  should  be  plunged  into  a  bath, 
and  I  do  not  see  why  the  accoucheur  should  refuse  this  little  grati- 
fication to.  the  parents  when  they  desire  to  have  it  done ;  if  I  gene- 
rally neglect  it,  it  is  because  it  takes  up  too  much  time,  and  assu- 
redly does  not  deserve  to  be  made  of  so  much  consequence  as  is 
done  by  some  accoucheurs. 

1217.  It  is  diflicult  to  conceive  how  certain  grave  authors  can 
defend  the  conduct  of, the  ancient  people  of  Germany,  Britain, 
Scythia,  and  Greenland,  and  recommend  the  Lacedeemonian  custom 
of  plunging  the  fcetus  into  cold  water  or  ice-water,  or  even  to  roll 
it  in  the  snow  immediately  after  its  birth,  as  appears  to  be  still  the 
practice  in  some  remote  districts  of  the  .vast  empire  of  Russia. 
The  vigour  and  the  robust  constitution  of  those  people  depended 
upon  their  diet  and  the  exercises  to  which  they  were  accustomed. 
If  they  iiad  among  them  no  weak  and  delicate  children,  that  may 
be  accounted  for,  not  by  saying  that  the  cold  bath  gives  strength 
and  health  to  weakly  children,  but  that  tlioso  that  were  weakly 


CLEANING  AND  DRESSING  THE  CHILD.  559 

at  first  soon  died,  and  that  none  remained  but  such  as  were  endowed 
with  more  vigorous  constitutions.  This  practice  was  quite  a  natural 
test  among  a  people  who  desired  to  have  in  their  republic  none  but 
strong  citizens,  and  looked  upon  infirm  men  as  more  troublesome 
than  useful ;  but  in  our  present  state  of  civilization  the  most  robust 
men  are  not  always  those  who  perform  the  most  important  parts  in 
the  state ;  it  is  no  longer  allowable  to  be  careless  of  the  life  of  any 
individual,  and  every  child,  whether  delicate  or  vigorous,  has  an 
equal  right  to  the  protection  of  its  parents  and  of  society  in  general. 
The  fcEtus  has  enough  to  do  to  bear  the  intemperature  of  the 
atmosphere ;  and  can  any  thing  be  more  absurd  than  to  wish  to 
make  it  pass  at  once  from  a  temperature  of  32°  of  Reaumur  to 
some  degrees  below  zero  ?  A  transition  so  sudden  as  this  in  a 
being  so  frail — is  it  natural  ?  Even  although  it  should  be  effected 
by  degrees,  as  Rousseau  wished,  it  would  nevertheless  be  dangerous 
and  wrong. 

1218.  Medicated,  alcoholic,  or  strengthening  baths  seem  to  me 
to  deserve  the  same  reprobation,  as  a  general  rule :  if  they  are 
strong  they  deprive  the  skin  of  its  suppleness,  interfere  with  the 
expansive  movement  of  the  fluids,  and  may  give  rise  to  the  most 
serious  accidents ;  if  weak,  they  at  least  do  no  good,  and  I  should 
not  make  use  of  them  except  where  the  foetus  might  be  excited  in 
a  general  manner,  so  as  to  communicate  a  greater  degree  of  activity 
to  its  languid  functions.  Thus,  except  under  particular  indications, 
lotions  and  baths  of  plain  warm  water  Sre  the  only  ones  that  pru- 
dence permits  us  to  recommend. 

§.  III.  Of  dressing  the  child. 

1219.  The  foetus  being  washed,  cleaned  ftnd  wiped  dry,  still  re- 
quires some  attention ;  the  accoucheur  should  direct  its  first  dress- 
ing ;  he  should  at  least  superintend  the  application  of  the  belly  band 
and  the  cutting  of  the  cord. 

The  form  of  this  compress,  in  itself  considered,  is  of  little  conse- 
quence ;  Baudelocque  directs  it  to  be  made  double,  and  that  a  pretty 
deep  cut  of  a  half  moon  shape  should  be  made  in  the  folded  edge 
with  the  scissors ;  that  after  splitting  one  of  the  halves  from  the 
hole  quite  out  to  the  end,  the  root  of  the  cord  should  be  lodged  in 
the  space  between  ;  that  the  part  not  split  should  remain  below,  and 
the  two  halves  of  the  divided  portion  should  be  turned  over  and 
crossed  in  front.  There  is  another  method.  Let  the  compress  be 
placed  at  the  upper  and  left  side  of  the  abdomen,  rather  than  at  the 
right,  on  account  of  the  presence  of  the  liver ;  a  second  compress, 
soft  and  of  a  square  shape,  covers  the  first ;  a  band  as  wide  as  three 


560  MANAGEMENT  OF  THE  CHILD. 

or  four  fingers,  and  long  enough  to  go  once  and  a  half  round  the 
belly,  keeps  the  whole  in  place  ;  this  band  is  fastened  at  the  side 
rather  than  at  the  middle  of  the  belly,  with  a  pin,  which  i§  far  from 
being  so  dangerous  as  some  persons  have  supposed,  or  it  may  be 
secured  with  a  needle  and  thread.  If  drawn  too  tightly  it  would 
do  harm,  if  too  loose,  it  would  slip  off,  and  do  no  good.  This 
little  apparatus,  the  object  of  which  is  to  prevent  the  cord  from 
being  pulled  or  stretched,  and  from  sticking  to  the  skin,  ought  to 
be  continued  or  reapplied  until  the  cord  drops  off.  It  may  even  be 
continued  for  some  days,  some  weeks,  or  months  afterwards,  pro- 
vived  the  navel  projects  too  much,  or  there  is  any  danger  of  an  om- 
phalocele taking  place.  The  cord  generally  separates  from  the 
navel  about  the  fifth  day  ;  but  in  some  children  it  takes  place  as 
early  as  the  second,  while  in  others  it  does  not  happen  until  the 
ninth  or  tenth  day.  It  begins  to  dry  at  its  loose  end,  as  has  been 
correctly  observed  by  M.  Billard  ;  the  gelatin  which  it  contains  con- 
tracts upon  the  vessels,  which  are  soon  somewhat  strangulated  by 
it,  as  far  as  the  umbilical  ring,  and  not  by  the  epidermis,  as  M. 
Gardien  supposed.  Being  reduced  to  a  mere  pedicle  which  grows 
smaller  and  smaller,  the  vessels  soon  separate  from  the  living  parts, 
so  that  the  gangrene  of  which  Haller  speaks,  the  contraction  indi- 
cated by  Gardien,  the  eliminative  inflammation  observed  by  Beclard, 
Chaussier,  and  M.  Orfila,  as  well  as  the  kind  of  putrefaction  noticed 
M.  Denis,  are  merely  accidental  phenomena,  and  not  the  cause  of 
the  fall  of  the  cord.  When  a  small  wound  is  left  after  the  separa- 
tion of  the  cord,  it  generally  heals  spontaneously  in  from  eight  to 
twelve  days.  All  the  ointments  and  waters  recommended  by  the 
good  women  to  force  it  to  close  sooner  are  of  no  use,  and  might 
even  produce  an  opposite  effect.  It  is  suflicient  to  cover  it  with  a 
piece  of  fine  dry  linen,  or  to  sprinkle  it  over  with  a  little  flour  or 
powder  of  lycopodium. 

1220.  Previously  to  wrapping  up  the  navel  string,  it  was  formerly 
the  custom  to  begin  to  dress  the  child  and  cover  the  head,  arms  and 
breast.  Thanks  to  the  elegant  pen  of  Rousseau,  it  is  rarely  neces- 
sary for  us  at  the  present  day  to  combat  the  employment  of  those 
absurd  swaddling  bands,  which  render  a  new  born  infant  an  im- 
movable mass,  a  sort  of  doll  which  could  be  taken  hold  of  by  the 
feet  and  lifted  up  stiff.  The  reform  upon  this  subject  is  carried  so 
far  in  England,  that  instead  of  the  barra-coat  they  make  use  of  a  long 
frock,  a  sort  of  sac  of  fine  wool  stuff,  which  serves  for  the  dress  of 
the  child.  In  France,  they  also  put  a  shirt,  or  small  woollen  jacket, 
provided  with  a  soft  chemisfette,  which  is  fastened  behind  with  pins  ; 
it  is  then  wrapped  in  a  linen  barra  and  another  made  of  wool  or 


DRESSING  OF  THE  CHILD.  561 

cotton.  These  barras  come  up  as  high  as  the  axillae,  and  go 
once  and  a  half  round  the  body,  and  cross  in  front  all  the  way 
down  ;  the  end  is  then  folded  up  so  as  to  reach  quite  to  the  upper 
part  of  the  breast,  and  the  corners  are  carried  round  behind,  to  the 
back,  where  they  are  also  fastened  with  pins. 

However,  all  these  matters  belong  rather  to  the  women,  and  par- 
ticularly the  nurses,  than  to  the  physician.  Provided  that  the  child 
is  comfortable,  free  in  its  motions,  the  dress  soft  and  warm,  it  is 
of  small  consequence  what  shall  be  its  form,  nature,  or  arrange- 
ment ;  every  thing  over  and  above  these  points  should  be  left  to  the 
taste  or  caprice  of  the  family  or  assistants. 


Gft 


SECTION  3. 
the  Fcetus  in  a  State  of  Disease. 


The  foetus  may  be  born  weak,  or  even  in  a  state  of  apparent 
death  ;  the  treatment  it  shall  receive  under  these  circumstances 
should  vary  according  to  the  dangejr  and  the  nature  of  the  accident 
which  compromits  its  life. 

§.  I.  Of  asphyxia. 

If  the  child  is  only  weak  without  being  actually  sick,  it  should  be 
treated  in  the  way  that  has  already  been  directed  ;  only  we  should 
sooner  attend  to  putting  the  finger  in  the  mouth  so  as  to  cleanse  it 
from  any  mucus  contained  in  it ;  great  care  is  to  be  taken  to  avoid 
cold;  a  little  wine  may  be  added  to  the  water  to  be  used  in  washing  it, 
and  nothing  is  to  be  done  that  might  in  any  way  whatever  interfere 
with  the  freedom  of  its  respiration. 

But  the  weakness  may  be  carried  to  the  extreme  ;  sometimes  the 
fcetus  neither  cries  nor  respires,  its  skin  is  pale  ;  the  circulation  is 
languid,  the  heart  scarcely  beats;  and  but  for  the  heat  which  remains, 
and  the  obscure  motion  of  the  umbilical  arteries  and  heart,  the 
death  of  the  child  would  be  evident. 

1221.  This  is  the  state  which  is  called  asphyxia  of  new  born 
children.,  which  M.  Gardien  prefers  to  denominate  syncope,  and 
wliich  others  have  denominated  anemia ;  but  which  in  fact  differs 
from  those  three  morbid  states  in  a  great  many  respects,  and  which, 
rigorously  speaking,  are  much  more  nearly  allied  to  the  latter  than 
to  the  two  former. 

It  is  met  with  particularly  after  very  precipitate  delivery,  where  the 
child  has  been  turned,  when  it  is  born  before  the  full  term,  where 
there  has  been  a  flooding  during  labour  or  several  days  before  it, 
3  V 


562  MANAGEMENT  OF  THE  CHILD. 

especially  that  kind  of  flooding  which  is  caused  by  implantation  of 
the  placenta  over  the  03  uteri,  or  that  which  comes  direct  from  the 
vessels  of  the  cord. 

Its  cause  therefore  is,  on  the  one  hand,  a  deficiency  of  blood, 
which  does  not  pass  through  the  brain  and  lungs  in  sufficient  quan- 
tity to  keep  those  organs  in  a  state  of  action ;  on  the  other,  the  want 
of  incitation  of  the  inspiratory  muscles,  and  perhaps  also,  in  some 
cases,  the  presence  of  too  great  a  quantity  of  mucus,  or  wa- 
ter of  the  amnios  in  the  trachea,  as  supposed  by  Heroldt  and 
Scheele;  M.  Desormeaux  seems  to  agree  with  Freteau,  that  the 
compression  of  the  cord  may  also  occasion  it,  by  closing  the  passage 
for  the  blood  in  the  vein,  whilst  it  leaves  the  arteries  more  or  less 
permeable  ;  but  I  have  elsewhere  shown  what  ought  to  be  thought 
of  this  view  of  the  subject. 

Upon  the  whole,  it  seems  to  me  that  asphyxia  of  new  born  chil- 
dren ought  to  be  attributed  to  the  affection  suffered  by  the  blood 
in  the  last  moments  of  the  labour,  its  placental  modification,  and  its 
having  ceased  to  be  subjected  to  that  sort  of  internal  respiration 
which,  under  ordinary  circumstances,  is  kept  up,  until  the  real  respi- 
ration becomes  positively  established. 

1222.  Treatment.  The  first  thing  to  be  done  is  to  remove  the 
▼iscid  mucus  from  the  mouth  by  means  of  the  finger,  or  with  a  brush, 
•feither  dry,  or  dipped  in  a  solution  of  common  salt ;  there  is  no  rea- 
son to  believe  that  it  is  either  safe  or  useful  to  turn  the  foetus  with 
the  face  downwards  to  force  the  matters  contained  in  the  trachea  to 
escape  therefrom,  nor  to  suck  them  out  into  a  tube  as  Heroldt  and 
Scheele  state  that  they  have  done.  Where  there  is  reason  to  be- 
lieve that  the  placenta  still  maintains  a  part  of  its  natural  relations 
with  the  womb,  and  especially  where  there  is  still  some  tremor, 
some  pulsation  in  the  cord,  we  may  follow  the  advice  of  Levret, 
Smellie,  Freteau,  M.  Piet,  Chaussier,  &c.  not  to  cut  it  too  soon ; 
but  if  the  wpmb  be  well  contracted,  if  the  adhesions  of  the  placenta 
be  evidently  destroyed,  it  would  bo  better  to  separate  the  foetus  at 
once  from  its  mother.  The  fact  related  by  A.  Petit,  wherein  he 
saw  the  child  in  some  measure  die  and  revive  again  accordingly  as 
the  cord  was  compressed  or  free,  to  command  our  entire  belief, 
would  require  a  fuller  detail  of  all  the  accompanying  circumstances. 
Supposing  that  the  secundines  are  either  wholly  expelled,  or  on  the 
point  of  being  expelled,  and  that  there  should  be  still  some  pulsa- 
tions in  the  cord,  I  should  not  object  to  keeping  them  for  some  lime 
in  warm  wine  and  water,  as  again  recommended  even  in  our  own 
day  by  many  authors,  as  MM.  Beauchesne  and  Dorthal  among 
others ;  but  in  other  cases  I  cannot  perceive  any  advantages  in  act- 


OF  ASPHYXIA.  56a 

ing  Ihus^  As  it  is  important  for  the  fcetus  to  preserve  what  little 
blood  it  has,  the  cord  should  be  tied  previously  to  cutting  it  off;  the 
child  is  to  be  immediately  taken  out  of  the  mother's  sight ;  it  should 
be  taken  near  a  good  fire,  or  it  may  be  plunged  up  to  the  axillse  in 
a  warm  bath,  rendered  somewhat  exciting  by  the  addition  of  a  little 
wine  or  brandy  ;  we  should  give  it  slight  shocks  by  slapping  it  with 
the  flat  of  the  fingers  upon  the  breast,  the  back,  or  the  breech  ;  the 
cord  should  also  be  gently  pulled  in  such  a  way  as  to  move  the  dia- 
phragm a  little.  Van  Svvieten  speaks  of  midwives  who  applied  the  . 
mouth  to  the  left  nipple  of  the  child,  and  derived  great  advantages 
from  suction  performed  on  this  or  other  parts  of  its  body.  Instead 
of  the  mouth,  a  cup  might  be  made  use  of.  This  practice,  which 
was  reinstated  by  Saccombe,  M.  Desormeaux  thinks  may  be  of 
some  use,  by  exciting  the  action  of  the  muscles ;  but  it  cannot  pro- 
duce, as  is  pretended,  a  real  mechanical  dilatation  of  the  chest.  The 
temples,  the  nostrils,  the  forehead,  the  root  of  the  neck,  and  the 
spine,  ought  to  be  rubbed  with  the  fingers  dipped  in  cologne  water, 
alcohol,  &c.  or  with  a  pretty  stiff  dry  brush ;  the  inside  of  the  mouth 
and  nose  are  to  be  stimulated  by  the  introduction  of  vinegar,  brandy, 
or  some  other  irritating  liquor,  or  merely  with  the  barbs  of  a  dry 
feather.  I  have,  in  imitation  of  M.  Desormeaux,  advantageously 
employed  a  mouthful  of  spirituous  liquor,  held  a  few  moments  in  the 
mouth  and  then  spirted  with  force,  in  the  form  of  a  douche.,  or  of  ab- 
lution over  the  breast  of  the  child:  the  smoke  of  burnt  linen  or  paper 
introduced  into  the  rectum  has  been  beneficially  employed  in  some 
cases;  some  onion  or  garlic  introduced  into  the  anus,  the  mouth,  or  the 
nose,  produce  nearly  the  same  effect,  and  are  not  so  dangerous  as  am- 
monia or  radical  vinegar,  which  promptly  act  as  caustics  if  not  largely 
diluted  with  water.  The  belly  and  thorax  should  be  simultaneously 
and  properly  pressed  so  as  to  try  to  induce  the  diaphragm  to  contract; 
and  during  all  these  processes  the  foetus  should  be  always  kept  very 
warm,  for  without  this  precaution  the  action  of  all  the  other  means 
will  generally  be  inefficacious.  We  should  persevere  with  them  for 
a  long  time,  and  not  get  tired,  and  redouble  our  patience  as  soon  as 
the  least  sign  of  life  becomes  manifest;  sometimes  the  efforts  of  the 
accoucheur  are  not  crowned  with  success  until  after  they  have  been 
continued  iialf  an  hour,  an  hour,  or  even  two  hours,  and  cases  are 
-not  wanting  where  children,  after  being  several  hours  abandoned  as 
dead,  have  come  to  life,  without  any  other  succour  than  the  temper- 
ature of  the  place  where  they  were  deposited. 

1223.  When  these  different  means  prove  ineffectual,  recourse  is 
to  be  had  to  inflating  the  lungs,  which  may  be  done  either  through 
a  quill-barrel,  a  female-catheter,  or  any  kind  of  canuta  introduced 


564  MANAGEMENT  OF  THE  CHILD. 

into  the  mouth  and  nostrils,  or  by  merely  blowing  with  the  mouth 
directly  into  the  air-passages.  The  laryngeal-tube  invented  by 
Chaussier,  having  the  advantage  of  pretty  exactly  filling  the  glottis 
when  introduced  into  it,  is  better  than  the  straight  canula  of 
Heroldt ;  but  a  simple  gum-elastic  catheter,  an  instrument  which 
may  be  got  any  where,  is  almost  as  convenient ;  it  is  introduced 
through  the  mouthy  as  far  as  the  bottom  of  the  pharynx  ;  then,  while 
it  is  passed  onwards,  the  point  of  it  may  be  bent  with  the  little  finger, 
so  as  to  compel  it  to  enter  into  the  larynx  rather  than  the  oesopha- 
gus; when  fixed  right,  the  nostrils  and  mouth  of  the  foetus  are 
closed,  and  the  inflation  commenced.  However,  if  it  should  be 
admitted  that  the  experiments  tried  by  Winslow,  Heroldt,  Scheele, 
Viborg,  Schmidt  and  Beclard,  incontestibly  prove  that  the  liquor 
amnii  penetrates  during  intra-uterine  life  as  far  as  the  bronchia,  it 
would  perhaps  be  useful  to  free  the  trachea  from  it  by  suction  or 
otherwise,  previously  to  trying  the  effects  of  inflation  ;  but  there 
is  still  too  much  uncertainty  upon  this  point  for  it  to  serve  as  a  basis 
for  any  practice  whatever. 

1224.  Curry,  Chaussier,  and  others,  had  at  first  thought  that  by 
blowing  into  the  mouth  none  but  vitiated  or  more  or  less  changed 
air  was  forced  into  the  lungs  of  the  foetus,  and  that  it  would  be 
better  to  make  use  of  a  bellows;  but  it  was  soon  found  that  all  these 
precautions  were  useless,  that  air,  slightly  warmed  in  the  lungs  of 
an  adult,  and  charged  with  a  gentle  humidity,  would  be  more  con- 
genial to  the  lungs  of  the  child  than  a  drier  and  colder  air.  Be- 
sides, Heroldt  and  others  have  proved,  that  the  gas  given  out  by  ex- 
piration, contains  only  one  hundredth  less  of  oxygen  than  atmos- 
pheric air. 

As  it  is  important  that  the  air  should  enter  the  lungs  and  not 
the  alimentary  canal,  an  assistant  ought  to  press  his  hand  against  the 
larynx,  so  as  to  keep  it  against  the  cervical  vertebra,  and  flatten  the 
oesophagus  as  much  as  possible 

1225.  We  should  blow  at  first  very  gently.  When  the  lungs  are 
sufficiently  filled  to  lower  the  diaphragm  and  raise  the  sides  of  the 
thorax,  as  is  done  in  a  natural  inspiration,  we  must  stop,  nnd  gently 
compress  the  abdomen  and  breast  in  imitation  of  the  act  of  expira- 
tion. We  then  begin  again  in  the  same  manner,  and  thus  establish 
a  sort  of  artificial  respiration,  the  advantages  of  which  have  cer- 
tainly been  exaggerated  by  some  authors:  M.  Desormeaux  has  been 
but  imperfectly  satisfied  with  it,  and  in  my  hands  it  has  succeeded 
in  but  a  small  number  of  cases,  and  (according  to  the  researches  of 
M.  Lcroy  d'EtioUes)  it  is  really  dangerous  unless  managed  with 
very  great  care. 


ASPHYXIA.  565 

In  fact,  it  is  not  the  action  of  the  lungs,  but  that  of  the  respiratory 
muscles  that  ought  to  be  first  put  in  play.  But,  as  the  very  reverse 
takes  place  in  inflation,  it  follows,  according  to  M.  Leroy,  that 
the  air  generally  stops  in  the  large  branches  of  the  bronchia,  and 
that  we  can  rarely  succeed  in  forcing  it  into  the  air-cells,  without 
the  risk  of  producing  an  emphysema,  which  of  itself  is  sufficient  to 
occasion  the  death  of  the  individual. 

The  operation  of  tracheotomy,  proposed,  in  despair  of  any  thing 
better,  by  M.  Heroldt,  as  it  is  very  dangerous  in  itself  considered, 
offers  no  advantages  superior  to  simple  inflation,  and  ought  to  be 
proscribed. 

J 226.  Electricity  and  galvanism,  which  have  been  recommended 
under  these  circumstances  by  Greve,  Behosends,  Boer,  M.  Gardien, 
&c.  might  also  be  of  great  service  either  as  a  principal  or  accessory 
cause  in  the  treatment  of  the  asphyxia  of  n.ew  born  children.  The 
current  should  be  directed  through  the  breast,  or  from  the  mouth  to 
the  anus.  I  must,  notwithstanding,  confess  that  I  have  twice  tried 
it  without  success,  although  I  made  use  of  a  double  battery  of 
twenty-one  metallic  plates,  the  action  of  which  was  very  strong. 
The  electro-puncture  which  was  tried  by  M.  Leroy  on  animals, 
might  perhaps  be  more  efficacious,  by  permitting  it  to  act  directly 
upon  the  diaphragm  ;  but,  so  far  as  I  know,  it  has  never  been  ap- 
plied to  the  human  fcetus. 

If  we  are  to  succeed,  the  pulsations  of  the  heart  and  cord  re-ap- 
pear by  degrees,  the  muscles  gradually  recover  their  natural  firm- 
ness, the  skin  becomes  slightly  coloured,  the  heat  returns,  and  then 
some  respiratory  movements,  feeble  and  irregular  at  first,  then  more 
and  more  decided,  soon  make  their  appearance  ;  cries  are  soon 
heard,  and  the  child  is  saved.  It  would,  however,  be  imprudent  to 
cry  out  victory  too  soon  ;  I  twice  succeeded  in  restoring  the  mo- 
tions of  the  heart,  and  the  respiration,  for  more  than  three  hours, 
by  means  of  inflation  and  galvanism,  in  two  children,  which  I  never- 
theless was  at  length  compelled  to  abandon. 

§.  II.  Of  the  apoplectic  state. 

1227.  Instead  of  coming  into  the  world  pale,  anemic,  or  exsangui- 
OU9,  the  child  is  sometimes  born  in  quite  a  contrary  condition  ;  its 
skin  is  of  a  bluish  red  or  livid  colour,  of  various  degrees  of  intensity, 
especially  on  the  face,  and  appears  as  if  thickened.  All  the  organs 
seem  to  be  the  seat  of  a  general  congestion,  the  limbs  are  soft  and 
motionless  ;  the  circulation  is  suspended,  either  wholly  or  in  part, 
in  addition  to  which,  all  the  other  signs  just  now  indicated  are  found 
to  be  present. 


566  MANAGEMENT  OF  THE  CHILD. 

It  should  also  be  understood  that  the  disease  may  exhibit  itself 
under  various  degrees  of  intensity,  and  produce  various  changes  in 
the  interior  of  the  body.  Upon  opening  the  dead  bodies  of  such 
children,  fluid  blood  is  often  found  extravasated  between  the  menin- 
ges or  in  the  very  substance  of  the  brain.  In  other  cases,  and  that 
most  frequently,  the  blood  is  not  found  to  have  escaped  from  the 
vessels,  or  only  forms  slight  ecchymoses  in  different  parts ;  but  it  is 
in  excess  in  all  the  organs,  which  are  engorged,  and,  as  it  urere, 
soaked  in  it. 

The  apoplectic  state  is  met  with,  especially  in  strong  children, 
after  long  and  difficult  labours,  the  application  of  the  forceps,  and 
pelvis  labours,  either  spontaneous  or  artificial ;  where  the  child  has 
remained  for  several  hours  under  the  direct  influence  of  the  uterine 
contractions  after  the  discharge  of  the  waters ;  where  it  has  pre- 
sented in  a  bad  position;  where  it  is  too  large  to  pass  with  ease 
through  the  various  passages  ;  where  a  loop  of  the  cord  strictures 
its  neck,  or  is  itself  in  any  way  compressed,  and  particularly  where 
any  of  these  accidents  occur  coincidently  with  a  previous  plethoric 
state. 

Its  immediate  cause  is  the  compression  or  engorgement  of  the 
brain ;  which,  however,  does  not  prevent  a  want  of  the  revivification 
of  the  blood  from  being  an  occasional  cause  of  it,  as  well  as  of  as- 
phyxia; and  M.  Gardien,  while  opposing  the  sentiments  of  M. 
Chambon,  Courraut,  and  Capuron,  is  certainly  wrong  in  maintain- 
ing that  compression  of  the  cord  is  as  incapable  of  producing  the 
apoplectic  state  as  it  is  capable  of  easily  producing  asphyxia. 

1228.  When  a  child  is  born  in  this  state  we  should  make  haste 
to  disengorge  its  vascular  system  ;  by  acting  soon,  wjiere  there  is  no 
effusion,  the  alarming  symptoms  may  generally  be  soon  dissipated. 
Under  the  opposite  circumstances,  death  is  commonly  inevitable ; 
but,  as  has  been  remarked  by  M.  Dcsormeaux,  inasmuch  as  it  is 
impossible,  a  priori.,  to  distinguish  a  simple  congestion  from  an  en- 
cephalic hemorrhage,  the  accoucheur  would  be  reprehensible  who 
should  fail,  in  any  case,  to  bestow  upon  the  child  the  same  care  as  if 
the  affection  were  known  to  be  less  serious. 

If  the  accident  have  been  occasioned  by  compression  by  the  cord 
upon  the  jugular  vein,  the  turns  should  be  quickly  cast  off,  or  cut, 
provided  the  foetus  cannot  be  otherwise  freed  from  their  injurious 
effects.  In  other  cases  it  would  be  equally  dangerous  to  wait  for 
the  child  to  cry  before  cutting  the  cord,  or  to  amuse  ones-self  with 
immersing  the  placenta  in  a  warm  liquid.  The  section  of  the  cord 
is  the  first  and  chief  remedy  to  be  resorted  to.  The  ligature  is  not 
to  be  applied  until  after  the  disappearance  of  every  bad  symptom, 


I 


APOPLECTIC  STATE.  567 

because  the  advantage  of  this  section  is,  that  it  gives  free  issue  to 
the  blood.  To  promote  the  escape  of  this  fluid,  it  is  sometimes 
requisite  gently  to  press  upon  the  breast,  the  abdomen,  and  the 
cord  itself.  As  the  blood  flows  the  child  seems  to  revive ;  the  livid 
colour  of  the  lips  is  soon  replaced  by  a  purplish  or  rosy  hue ;  the 
parts  about  the  mouth,  and  nose,  the  rest  of  the  face,  and  the  whole 
surface  of  the  body  clear  up  by  degrees ;  the  respiration  soon  be- 
comes established,  and  in  a  few  minutes  the  danger  has  wholly  dis- 
appeared ;  but  the  circulation  is  sometimes  so  much  enfeebled  and 
obscure  that  no  blood  flows  from  the  umbilicus.  In  such  cases  we 
ate  obliged  to  resort  to  the  remedies  recommended  for  asphyxia, 
that  is  to  say,  to  frictions,  stimulating  baths,  inflation,  electricity, 
&c. ;  and  as  it  is  absolutely  necessary  for  the  child  to  lose  blood, 
provided  it  be  impossible  to  obtain  any  from  the  cord,  a  leech  should 
be  applied  behind  each  ear  to  disengorge  the  brain. 

1229.  When  the  integuments  have  recovered  their  natural  colour, 
the  circulation  has  returned  to  its  natural  state,  the  respiration  is 
no  longer  doubtful,  and  the  foetus  cries  and  moves  freely  ;  the  bleed- 
ing must  be  stopped,  provided  it  should  not  have  stopped  of  itself. 
After  this  we  proceed  as  if  the  child  had  been  born  well.  On  the 
contrary,  should  there  still  remain  some  obstruction  in  the  pulmo- 
nary and  cerebral  functions,  as  have  too  frequently  been  noticed, 
especially  where  we  have  been  unable  to  procure  a  sufficient  quan- 
tity of  blood,  leeches  ought  again  to  be  applied,  and  are  almost 
the  only  agents  upon  which  we  can  place  any  reliance,  in  cases 
where  congestion,  a  sort  of  secondary  apoplexy,  does  not  come  on 
until  twelve,  twenty-four,  or  forty-eight  hours,  or  even,  as  has  hap- 
pened, until  three  or  four  days  after  its  birth. 

§.  III.  Of  some  other  morbid  states  of  the  new-born  child. 

1230.  It  is  not  a  part  of  my  subject  here  to  treat  of  the  contu- 
sions, wounds,  luxations,  and  fractures  which  take  place  in  certain 
difficult  labours  ;  neither  have  I  occasion  to  speak  of  what  is  called 
tongue-tied,  adhesion  of  the  tongue,  occlusion  of  the  palpebrae  or 
lips,  imperforation  of  the  urethra,  vagina  or  anus,  of  jaundice,  in- 
duration of  the  cellular  tissue,  nor  any  of  the  faulty  conformations 
or  numerous  diseases  to  which  the  infant  is  subject ;  but  I  cannot 
pass  over  in  silence  the  deformity  of  the  head  and  some  other  acci- 
dents which  depend  directly  upon  the  compression  of  the  head 
during  its  passage  through  the  straits. 

1231.  The  depression  of  the  parietal  or  frontal  bone  with  or 
without  fracture,  has  been  several  times  observed  at  the  Maternite 
at  Paris  by  Chaussier,  M.  Duges,  and  Madame  Lachapelle  ;  there 


568  MANAGEMENT  OF  THE  CHILD. 

is  reason  to  fear  its  occurrence  when  the  head  rests  against  the 
sacro-vertebral  angle,  and  is  for  a  long  time  subjected  to  violent 
efforts,  when  the  strait  is  reniform^  and  when  a  pretty  large  head  is 
forced  to  mould  itself  to  the  form  of  the  pelvis  through  which  it 
passes. 

If  the  fracture  or  depression  of  the  bones  is  not  accompanied  with 
extravasation,  nature  ordinarily  succeeds  in  restoring  every  thing  to 
its  proper  condition,  and  performs  the  cure  herself ;  otherwise,  death 
is  the  common  consequence,  or  at  least,  there  ensues  stupor  and  a 
very  great  tendency  to  convulsions. 

1232.  By  moulding  itself  according  to  the  contracted  straits,  the 
head  may  be  elongated  without  its  bones  being  depressed  or  fractured, 
but  in  such  a  way  that  their  edges  cross  and  over-ride  one  another, 
more  or  less;  in  these  cases  they  pretty  often  recover  their  natural  po- 
sition after  the  delivery;  but  they  may  also  continue  to  over-ride,  as 
occurred  in  one  case  under  my  own  notice,  and  thus  constitute  a 
perpetual  cause  of  disease,  particularly  of  convulsive  affections. 

However,  in  this,  as  in  the  preceding  cases,  art  can  do  nothing, 
and  we  are  obliged  to  trust  to  the  powers  of  nature. 

1233.  A  more  common,  and  fortunately  less  serious  accident 
than  these,  is  a  sort  of  subcutaneous  effusion,  a  swelling  of  the 
hairy-scalp^  which  is  almost  always  met  with,  but  in  different  de- 
grees, when  the  head  has  traversed  the  pelvic  canal  slowly  and  with 
difficulty  ;  this  tumour  is  generally  found  on  that  part  of  the  cranium 
which  occupied  the  open  space  in  the  pelvis  during  the  labour  ;  or 
one  of  the  points  that  was  longest  and  most  forcibly  pressed  against 
the  sacro-vertebral  angle  or  pubis  ;  it  is  composed  in  some  cases  of 
reddish  serum,  in  some  of  pure  blood,  either  fluid  or  coagulated,  in 
others  of  a  mixture  of  these  fluids,  and  is  of  various  size,  from  that 
of  a  nut  up  to  that  of  a  hen's  egg. 

It  may  be  diffused  or  circumscribed,  and  it  may  be  fluctuating, 
though  generally  elastic  and  dough-like,  and  commonly  disappears 
without  any  assistance;  sometimes,  however,  it  suppurates  and  is  con- 
verted into  a  real  abscess,  which  may  end  in  denudation  and  necrosis 
of  the  cranial  bones. 

Being  soft  and  compressible  in  the  centre,  and  firmer  and  more 
elevated  about  the  edges,  it  has,  on  more  than  one  occasion,  been 
mistaken  for  a  fracture  or  depression  of  the  bones,  and  excited  use- 
less alarm.  But  since  J.  L.  Petit,  Ledran  and  Levret  have  called 
attention  to  this  sort  of  mistakes,  they  have  become  more  and  more 
rare. 

1234.  When  the  tumour  is  of  small  size,  it  should  be  left  to  itself, 
and  disappears  in  the  course  of  three  or  four  days,  leaving  behind  it 


TABLE  V. 

Table  showing  the  Mortality  of  Lying-in  Women  in  different  Coun- 
tries and  at  different  Periods ;  from  the  Registers  of  the  Dub- 
lin Lying-in  Hospital^  MM.  De  Chateau-Neuf,  Dbges,  &c. 


Years.     Labours.   Deaths, 


Dublin    LxiNG-iif 

HOSPITAL. 


1757 
1758 
1759 
1760 
1761 
1762 
1763 
1764 
1765 
'1766 
1767 
1768 
1769 
1770 
1771 
1772 
1773 
1774 
1775 
1776 
1777 
1778 
1779 
1780 
1781 
1782 
1783 
1784 
1785 
1786 
1787 
1788 
1789 
1790 


55 

454 

406 

556 

521 

533 

488 

588 

533 

581 

664 

655 

642 

970 

695 

704 

694 

681 

728 

802 

835 

927 

1011 

910 

1027 

990 

1167 

1261 

1292 

1351 

1347 

1469 

1435 

1546 


5 

4 

9 

6 

9 

12 

6 

3 

11 

16 


5 

4 

13 

21 

5 

7 

7 

10 

S 

5 

6 

6 

15 

11 

8 

8 

10 

23 

25 

12 


Years.  Labours.  Deaths 


1791 

1792 

1793 

1794 

1795 

1790 

1797 

1798 

1799 

1800 

1801 

1802 

1803 

1804 

1805 

1806 

1807 

1808 

1809 

1810 

1811 

1812 

1813 

1814 

1815 

1816 

1817 

1818 

1819 

1820 

1821 

1822 

1823 


1602 
1631 
1747 
1543 
1503 
1621 
1712 
1604 
1537 
1837 
1725 
1985 
2028 
1915 
2220 
2406 
2511 
2665 
2889 
2854 
2561 
2676 
2484 
2508 
3075 
3314 
3473 
35S9 
3197 
2458 
2849 
2675 
2584 


M.  DroES,  at  the  Ma- 
ternity of  Paris. 


f     1799 

1364 

100 

1800 

1155 

120 

1801 

1209 

25 

1802 

1496 

13 

1803 

16.32 

108 

1804. 

1662  . 

59 

1805 

1564 

60 

1806 

1625 

114 

1807 

1691 

72 

I  ■  1808 

1690 

57 

1809 
1810 
1811 
1814 
1815 
1816 
1817 
1818 
1819 


1795 
1814 
2395 
2384 
2346 
2422 
2800 
2411 
1528 


M.  De  Chatbau- 
N»UF,  at  Paris. 


{ 


1816 

9,683 

81 

1819 

11,580 

1817 

10,528 

90 

1820 

11,634 

1818 

ll,6f.2 

167 

1821 

11,481 

At 


WasseiHia,  in  Sweden,  1  death  in  62. 
Berlin,  ....  109  in  10,000. 
British  Hospital,  .  1  in  50. 
Manchester,  1  in      128. 


At. 


Hotel-Dieu,  Paris,  .  .  1  in  15. 
Lotfdon,in  SO  years,8ao  in  10,000. 
Strasburgh,  ...  1  in  109. 
Petersburgh, ...     7  in  1000. 


DISEASES  OF  THE  CHILD.  569 

only  a  simple  ecchymosis ;  but  its  resolution  may,  and  indeed  should 
be  facilitated,  by  keeping  it  covered  with  compresses  dipped  in  salt 
water,  red  wine,  or  brandy  and  water,  some  eau-blanche  or  other  me- 
dicine of  the  same  kind.  Should  it  be  fluctuating  and  not  very  painful, 
it  should  nevertheless  be  resolved  if  possible  ;  if  the  means  above  in- 
dicated do  not  suffice,  they  might  be  replaced  by  a  solution  of  half 
an  ounce  of  hydro-chlorate  of  ammonia  in  a  pint  of  red  wine ;  this 
liquor,  which  is  recommended  by  Siebold,  and  frequently  employed 
by  M.  Boyer  for  bloody  tumours  of  the  knee,  has  many  times  suc- 
ceeded in  dispersing  collections  which  it  had  seemed  indispensably 
necessary  to  open. 

However,  should  it  not  produce  the  effect  expected  from  it,  and 
the  fluctuation  increase,  recourse  must  be  had  to  the  bistoury  ;  and 
in  such  a  case  we  ought  not  to  wait  too  long,  which  would  admit  of 
the  skin  becoming  more  extensively  detached,  and  much  thinner. 
The  wound  should  be  dressed  with  lint,  cerate,  or  cataplasms,  that 
is  to  say,  as  we  would  dress  an  abscess  or  any  sanguine  collection  of 
a  common  kind,  and  the  wound  generally  heals  very  speedily. 


ARTICLE  III. 

Management  of  the  Lying-in  fVoman. 

1235.  The  accoucheur  being  now  satisfied  as  to  the  condition  of 
the  child  and  delivery  of  the  aff;er-birth,  has  nothing  further  to  do 
except  to  attend  to  the  woman  herself.  After  ascertaining  that  the 
womb  is  well  contracted,  and  every  thing  in  a  natural  state,  he 
cleanses  (or  orders  it  done)  the  vulva,  the  thighs,  and  all  the  parts 
that  have  been  soiled  with  blood,  waters,  or  other  substances  during 
the  labour.  Some  warm  water,  either  simple  or  mixed  with  a  little 
wine,  provided  the  parts  are  soft  and  relaxed,  is,  with  the  addition  of 
a  piece  of  sponge,  all  that  is  necessary  in  this  little  operation. 

We  next  change  the  woman's  clothes  ;  the  chemise  ought  to  be 
long,  soft  and  wide,  and  either  open  in  front,  or  not,  and  it  should  have 
long  sleeves,  so  that  the  arms  may  not  be  exposed.  Over  this 
chemise  there  is  worn  a  cotton  shirt,  and  then  a  neck-handkerchief 
round  the  neck,  so  that  the  upper  part  of  the  breast,  which  is  gener- 
ally exposed  to  the  air,  may  be  rather  better  protected  than  the  rest  of 
the  body.  In  summer,  and  whenever  the  weather  is  not  cold,  these 
3  W 


570  MANAGEMENT  OF  LYING-IN  WOMEN. 

two  pieces,  together  with  the  head-dress,  compose  the  whole  of  the 
woman's  dress  ;  otherwise  she  puts  on  a  long  wadded  silk-gown 
open  in  front  all  the  way  down  ;  in  this  gown  there  is  the  double  ad- 
vantage of  being  warm,  and  very  light.  However,  like  the  dress 
of  the  child,  that  of  the  mother  is  a  matter  which  we  generally  leave 
to  the  nurse  ;  and  provided  the  several  pieces  be  sufficiently  large, 
and  their  number  and  thickness  suited  to  the  temperature  of  the 
weather,  or  the  habits  of  the  patient,  she  should  always  be  allowed 
to  arrange  her  dress  as  she  pleases.  The  same  may  be  said  as  re- 
gards the  head-dress,  except  that  it  would  not  always  be  safe  to 
permit  the  patient,  which  she  sometimes  requests,  to  have  her  hair 
cut,  or  sprinkled  with  salt. 

The  breasts  do  not  require  to  be  supported,  or  provided  with 
wadded  cushions,  unless  they  are  very  large,  and  where  there  is  fear 
of  taking  cold.  The  bandage  which  some  women  use  for  the  pur- 
pose of  compressing  them,  and  preserving  their  shape,  produces 
quite  a  contrary  effect ;  besides,  by  impeding  the  action  of  the  re- 
spiratory muscles,  it  may  oppose  the  return  of  blood  to  the  thorax, 
give  rise  to  apoplectic  symptoms,  as  happened  to  two  imprudent 
women  mentioned  by  Baudelocque,and  become  the  cause  of  a  num- 
ber of  diseases,  each  worse  than  the  other  ;  the  astringent  or  re- 
pellent cataplasms  employed  for  the  same  purpose,  and  to  prevent 
the  secretion  of  milk,  deserve  the  same  reprobation. 

1236.  I  would  say  as  much  of  the  belly-bandage  so  much  blamed 
by  De  la  Motte,  were  it  used  solely  for  the  gratification  of  a  vain 
coquetry,  but  I  think  it  useful  in  another  way.  In  this,  as  in  all 
other  things,  we  must  take  care  not  to  confound  the  abuse  with  the 
wise  and  reasonable  use  of  things. 

Doubtless,  by  strangulating  the  abdomen  with  a  towel,  to  reduce 
their  size  and  prevent  the  formation  of  scars  or  inevitable  wrinkles, 
women  expose  themselves  to  great  dangers,  without  any  chance  of 
obtaining  their  object ;  but  as  has  been  advanced  by  Smellie,  Bau- 
delocque,  M.  Gardien,  &:.c.  a  bandage  that  is  moderately  tight,  or 
simply  gives  a  good  support,  may  be  of  great  service,  and  counter- 
act the  formation  of  many  serious  diseases.  The  suddenness  with 
which  the  womb  empties  itself,  causes  the  abdominal  viscera  im- 
mediately after  delivery  to  be  all  at  once  relieved  from  a  long  con- 
tinued state  of  pressure  ;  the  abdominal  parietes,  as  they  do  not  fol- 
low up  the  retreating  movement  of  the  uterus,  no  longer  support 
the  digestive  organs  with  the  same  power;  a  kind  of  vacuum  is  ef- 
fected in  the  large  vascular  trunks,  and  the  blood  should  be  determin- 
ed there  with  so  much  the  greater  force,  as  it  had  only  penetrated 


MANAGEMENT  OF  LYING-IN  WOMEN.  571 

them  with  difficulty  for  some  months  ;  hence  arises  a  greater  ten- 
dency to  hemorrhage,  inertia  of  the  womb,  inflammations,  and  func- 
tional disturbances  of  the  liver  and  intestines.  Hence,  says  Van 
Swieten,  the  syncopes  that  are  so  frequently  met  with  in  women  re- 
cently delivered,  though  M.  Desormeaux  thinks  they  often  depend 
upon  hysteria;  again,  Stoll  thinks  that  this  is  the  principal  cause  of  the 
puerperal  peritonites.  Now,  the  bandage,  as  I  understand  it,  is  intend- 
ed to  supply,  as  far  as  possible,  the  action  of  the  abdominal  muscles,  to 
promote  the  concentric  movement  of  the  uterus,  and  prevent  the  af- 
flux of  blood  towards  that  organ  and  the  engorgement  of  all  the 
other  viscera  :  besides,  it  is  easy  to  acquire  an  idea  of  its  utility,  by 
reflecting  upon  the  dangers  that  follow  the  operation  of  paracentesis, 
where  the  surgeon  omits  the  precaution  of  applying  a  compressive 
bandage  upon  the  belly,  after  the  evacuation  of  the  fluid  ;  for  as  to 
degree,  the  pressure  upon  the  parts  contained  within  the  abdomen 
experiences  nearly  the  same  transition  in  a  woman  delivered  of  a 
child,  as  it  does  in  a  dropsical  patient  undergoing  the  operation  of 
tapping. 

It  is  true,  that  if  not  carefully  applied,  the  bandage  soon  rolls  up 
into  the  form  of  a  string,  and  becomes  morie  hurtful  than  useful ; 
that,  as  M.  Desormeaux  remarks,  most  of  those  women  who  neg- 
lect to  apply  it,  are  not  evidently  worse  oflTon  that  account,  and  that 
the  use  of  it  could  not  have  entered  into  the  original  plan  of  the  con- 
stitution ;  but  as,  when  placed  so  as  to  produce  no  uneasiness  nor 
pain,  I  cannot  perceive  how  it  can  do  any  harm,  and  as  in  many 
cases  it  is  incontestably  useful,  we  should  by  rejecting  it  expose  our- 
selves, without  any  motive,  to  see  symptoms  arise  which  at  first  it 
would  have  been  very  easy  to  repress  or  prevent. 

It  is  composed,  first,  of  a  towel  folded  into  a  triangular  shape, 
which  is  placed  on  the  hypogastrium  with  the  point  downwards,  and 
then  of  another  napkin  which  is  folded  once  or  twice  lengthways, 
and  passed  round  the  body  like  a  bandage,  embracing  the  hips. 

To  prevent  it  from  getting  into  folds,  the  last  napkin  should  be  sup- 
ported above  by  a  scapulary  or  the  two  ends  of  a  bandage  arranged 
like  suspenders,  and  below  by  pinning  the  ends  of  her  cloth  to  it. 

The  cloth,  formed  of  a  piece  of  fine  linen  folded  three  or  four 
times,  and  sufficiently  long  to  cover  the  vulva  and  go  to  be  pinned 
to  the  body  bandage  both  before  and  behind,  is  designed  to  receive 
the  fluids  that  are  discharged  from  the  vagina,  and  to  prevent  the 
bed-clothes  from  becoming  soiled  with  them  ;  when  care  is  taken  to 
renew  them  frequently,  and  not  to  pin  them  too  tightly,  none  of  the 
ill  eflects  will  ensue  so  justly  attributed  to  the  old  fashioned  cloth, 


572  MANAGEMENT  OF  LYING-IN  WOMEN. 

of  which  some  women  still  make  use,  and  which  consisted  of  various 
tampons  kept  in  the  vulva,  and  which  more  or  less  strictly  stopt  the 
passage  of  the  vagina.  Although  it  is  not  an  indispensaV)le  article 
of  dress,  it  seems  to  me  that  it  may  safely  be  permitted  as  a  means 
of  cleanliness  to  those  persons  who  desire  to  have  it,  or  who  set  any 
particular  value  upon  its  use. 

1237.  The  new  bed,  to  which  the  patient  is  about  to  be  transfer- 
red, ought  to  be  furnished  with  an  oil  cloth,  if  one  can  be  had,  and 
with  a  sheet  folded  into  four  layers,  or  of  any  other  piece  of  linen  fit  to 
protect  the  mattrass.  The  bed  clothes,  the  coverlids,  and  the  arrange- 
ment of  the  bolsters,  do  not  require  any  interference  on  the  part  of 
the  accoucheur,  and  ought,  like  every  thing  else,  to  be  suited  to  the 
season  and  the  habits  of  the  woman. 

She  is  to  be  transferred  to  the  new  bed  shortly  after  delivery, 
and  when  the  vagina  is  freed  from  the  clots  and  the  fluid  blood 
which  commonly  follow  the  expulsion  of  the  placenta.  She  is  then 
in  a  state  of  agitation,  and  can  without  inconvenience  bear  the  little 
shocks  which  the  transfer  almost  inevitably  occasions.  If  we  wait 
longer,  as  some  authors  have  recommended  from  fear  of  hemorrhage 
or  convulsions,  she  would  be  in  the  situation  of  the  traveller  who, 
having  reached  his  post  harassed  and  fatigued,  can  still  take  a  few 
steps  while  heated,  but  when  he  once  becomes  still  and  cooled,  is 
quite  unable  to  walk.  All  this,  howevef.  is  to  be  understood  of 
cases  in  which  every  thing  has  passed  naturally ;  for  if  the  womb 
should  not  contract  well,  or  should  there  have  been  any  flooding  or 
threatening  of  convulsions,  or  any  other  accidents  that  commonly 
ensue  from  a  state  of  extreme  weakness,  the  removal  should  be  de- 
ferred for  a  few  minutes,  in  order  to  allay  the  danger  or  give  time 
for  the  functions  to  return  to  their  natural  condition,  while  the  wo- 
man is  still  upon  the  bed  whereon  she  had  been  delivered. 

1238.  Those  who  get  up,  and  go  without  any  support  to  get  into 
the  other  bed,  run  the  risk  of  bringing  on  inversion,  antenersion  or 
retroversion,  prolapsion  of  the  uterus,  and  many  other  dangerous  com- 
plaints. They  ought  to  be  warned  of  it,  and  made  to  understand 
that  they  should  allow  themselves  to  be  carried ;  when  they  are 
very  weak,  ot  any  accident  has  supervened,  which  might  be  aggrava- 
ted or  recalled  by  too  much  motion,  the  two  beds  ought  even  to  bo 
placed  side  by  side,  for  in  this  way  the  woman  can  be  slid  on  the 
clean  bed  without  moving  her  much,  by  making  use  of  the  sheet  on 
which  she  laid  during  the  labour,  and  which  may  be  easily  removed 
afterwards. 

When  put  to  bed,  it  would  be  useless,  and  indeed  not  always  free 


MANAGEMENT  OF  LYING-IN  WOMEN.  573 

from  danger,  to  compel  her  to  preserve  an  attitude  that  she  is  un- 
accustomed to,  to  make  her  bed  represent  an  inclined  plane  for  ex- 
ample (descending  towards  the  foot),  for  the  purpose  of  favouring 
the  escape  of  the  lochia,  or  on  the  other  hand,  to  keep  her  hips 
raised  higher  than  her  head,  with  a  view  of  moderating  the  fluxion 
of  fluids  towards  the  genital  organs ;  she  will  lie  upon  the  back, 
with  the  legs  stretched  out  and  close  together,  should  that  position 
appear  more  convenient  and  not  fatiguing  to  her  ;  but  she  ought  not 
to  be  prevented  from  turning  on  the  side,  and  bending  her  limbs  if 
she  wishes  to  do  so.  In  all  respects  she  should  be  allowed  to  con- 
sult her  own  ease,  .and  her  own  inclinations  should  be  attended  to. 
The  fatigue  and  weakness  brought  on  by  the  constraint  of  a  fixed 
posture,  would  of  themselves  be  suflicient  to  bring  on  some  acci- 
dents, and  constitute  a  morbid  state,  even  in  a  healthy  person  sub- 
jected to  them  ;  and  they  should,  a  fortiori,  be  dispensed  with  in 
women  whose  functions,  being  temporarily  disturbed,  require  so 
much  care  and  caution  for  their  restoration  to  a  natural  state. 

1239.  All  that  has  been  said,  in  speaking  of  the  management  of 
a  woman  in  labour,  relatively  to  the  air  which  surrounds  her,  the 
chamber,  and  her  moral  condition,  is  equally  apphcable  to  her  dur- 
ing the  subsequent  confinement.  It  is  important  that  she  should 
neither  speak  nor  be  spoken  to,  except  when  necessary.  A  calm 
state  of  the  mind  and  repose  of  the  body  are  so  indispensable,  that 
too  much  care  cannot  be  taken  to  remove  every  cause  that  might 
interfere  with  them.  The  value  of  this  precept  was  so  well  under- 
stood in  ancient  Rome,  that  the  magistrates  themselves  had  no  right 
to  enter  the  house  of  a  lying-in  woman  for  the  execution  of  any 
sentence  or  decision  whatever ;  and  in  order  to  secure  the  re- 
spect of  the  citizens  for  her  asylum,  it  was  suflicient,  says  Juvenal, 
to  suspend  a  crown  at  her  door. 

Foribus  suspends  coronas, 
Jam  pater  es. 

Most  of  the  diseases  which  afl'ect  a  woman  in  child-bed  may  be 
attributed  to  the  thousands  of  visits  of  friends,  neighbours,  or  ac- 
quaintances, or  the  ceremony  with  which  she  is  too  often  oppressed: 
she  wishes  to  keep  up  the  conversation,  her  mind  becomes  excited, 
the  fruit  of  which  is  headach  and  agitation;  the  slightest  indiscreet 
word  worries  her  ;  the  slightest  motives  of  joy  agitate  her  in  the  ex- 
treme ;  the  least  opposition  instantly  makes  her  uneasy,  and  I  can 
affirm  that  among  the  numerous  "bases  of  peritonitis  met  with  at  the 


574  MANAGEMENT  OF  LYING-IN  WOMEN. 

Hospital  de  Perfectionnement,  there  are  very  few  whose  origin  is 
unconnected  with  some  moral  commotion. 

1240.  After  the  delivery  of  the  placenta,  and  putting  to  bed,  the 
woman  is  commonly  seized  with  a  rigor,  which  sometimes  goes  so 
far  as  to  occasion  a  rattling  of  the  teeth  together.  Some  physi- 
cians and  the  public  have  on  this  account  deemed  it  best  to  cover 
her  over  with  a  weight  of  bed-clothes  ;  but  this  rigor,  which  is  suffi- 
ciently accounted  for  by  the  changes  that  have  just  occurred  in  her 
system,  and  which  must  not  be  confounded  with  the  chill  of  perito- 
nitis, lasts  but  a  few  minutes,  and  scarcely  deserves  any  particular 
attention. 

It  would,  doubtless,  be  imprudent  to  cover  the  lying-in  woman  too 
lightly  ;  but  it  would  be  equally  dangerous  to  fall  into  the  opposite 
excess.  By  covering  her  with  thick  bed-clothes  and  surrounding 
her  with  well  closed  bed-curtains,  and,  in  fine,  by  keeping  her  too 
warm,  besides  the  headachs,  floodings,  and  convulsions  to  which 
she  would  be  exposed,  we  rarely  fail  to  produce  a  more  or  less  abun- 
dant perspiration,  which  it  is  sometimes  difficult  to  suppress  ;  this 
diaphoresis  probably  has  H  great  deal  to  do  in  producing  the  miliary 
fever,  which  is  so  uncommon  at  the  present  day,  and  which  was 
formerly  so  often  met  with  in  lying-in  women. 

1241.  Sleep  being  of  the  first  necessity  to  a  being  worn  out  with 
fatigue,  there  would  be  a  sort  of  cruelty  in  not  permitting  the  wo- 
man to  enjoy  it :  in  advising  that  she  should  be  kept  awake  for 
several  hours  for  the  purpose  of  avoiding  hemorrhage,  De  la 
Motte  certainly  did  not  in  this  morbid  phenomenon  distinguish  the 
effect  from  the  cause.  Although  women  sometimes  do  fall  asleep 
with  all  the  appearances  of  health,  and  wake  up  soon  aflerwards  in 
the  midst  of  a  profuse  flooding,  there  is  a  far  greater  number  who 
owe  their  well  being  only  to  the  benificent  influence  of  a  refreshing 
sleep.  Besides,  these  floodings  were  imminent,  or  had  even  begun 
at  the  time  the  women  fell  asleep  ;  the  desire  for  sleep  being  one 
of  their  most  common  symptoms  ;  if  they  should  be  unsuspected  at 
first,  and  the  woman  yields  to  the  necessity  she  feels,  she  in  fact 
falls  into  a  dangerous  sleep,  and  sometimes  never  awakes  from  it ; 
but  in  this  case  the  sleep  is  the  efiect,  and  not  the  cause  of  the  dis- 
ease ;  it  is  consequently  not  contra-indicated  by  any  thing  ;  only, 
prudence  requires  that  the  pulse  should  bo  watched,  and  that  the 
hand  should  from  time  to  time  be  placed  on  the  hypogastrium,  to 
ascertain  that  the  womb  has  not  fallen  into  a  state  of  inertia. 

AHer  this  first  sleep,  that  is  to  say,  after  the  lapse  of  two  or  three 


MANAGEMENT  OF  LYING-IN  WOMEN.  575 

hours,  she  should  set  up  in  bed  and  take  a  little  broth;  this  position 
serves  to  rest  her,  and  allows  the  lochia  which  had  accumulated  in 
the  vagina  to  flow  readily  off". 

In  the  following  days  her  linen  is  shifted  accordingly  as  she  gets 
it  soiled  ;  the  external  parts  of  generation  should  be  often  washed, 
and  cleansed  with  mallows-water,  which  may,  without  inconvenience, 
be  replaced  by  a  decoction  of  chervil  mixed  with  milk;  constipation, 
so  frequently  met  with  in  these  cases,  is  combatted  by  means  of 
mild  clysters,  without  regard  to  the  prejudice  which  decides  that  no 
clyster  should  be  givfen  previously  to  the  occurrence  of  milk  fever  : 
smarting  about  the  meatus  urinarius,  difficulty  of  making  water, 
hemorrhoids,  and  other  effects  of  the  frictions  which  must  be  ex- 
perienced by  the  bladder  and  rectum  while  the  foetus  is  passing  out, 
require  emollient  or  slightly  aromatic  lotions,  hip-baths,  and  some- 
times the  use  of  the  catheter. 

1242.  The  regimen,  both  alimentary  and  medicinal,  of  lying-in 
women,  is  a  point  deserving  the  whole  attention  of  the  accoucheur — 
not  on  account  of  the  number  or  energetic  quality  of  the  substances 
which  it  is  proper  to  administer,  but  because  there  are  no  where 
else  so  many  vulgar  practices  to  proscribe,  so  many  ridiculous  pre- 
judices to  extirpate,  as  upon  this  subject. 

Drink  should  only  be  given  to  satisfy  thirst,  and  not  for  the  mere 
pleasure  of  making  her  swallow  ptisan  ;  the  woman  requires  a  drink, 
and  not  a  medicine.  In  regard  to  this,  her  taste  and  idiosyncrasy 
may  be  consulted.  She  commonly  continues  to  use  one  of  the 
ptisans  which  she  had  been  advised  to  use  during  her  labour. 
When  tired  of  one,  another  is  given  to  her,  and  provided  they  do 
not  prescribe  some  of  those  bitter,  exciting  infusions,  or  some  active 
compound,  of  which  the  old  women  are  so  prodigal,  she  may,  in 
general,  be  allowed  to  take  what  pleases  her  best.  Hot  wine,  aro- 
matics,  alcoholic  tinctures,  coffee,  tea,  and  chocolate  are  not  more 
admissible  after  than  before  her  lying-in. 

The  food  should  be  light,  and  given  in  small  quantity :  broth  given 
one,  two,  or  three  times  a  day,  or  some  messes  of  potage,  are  all 
that  prudence  will  allow  before  the  milk  comes  to  flow  freely. 
Eichele  has  supposed  that  by  abstaining  even  from  the  broth, 
and  making  use  of  debilitating  measures,,  the  milk  fever  would  be 
prevented  from  coming  on ;  but  I  have  often  had  opportunities  of 
proving  the  absurdity  of  such  an  assertion.  If  the  woman  is  to 
suckle  her  child,  it  is  not  improper  to  allow  her  to  have  potages 
of  a  rather  more  substantial  kind  the  day  after  the  dehvery; 
in  the  opposite  case  I  give  nothing  but  broth.     Upon  this  subject, 


576  MANAGEMENT  OF  LYING-IN  WOMEN. 

attention  must  be  paid  to  her  state  of  health,  her  habits  and  consti- 
tution ;  we  ought  not,  for  example,  obstinately  to  restrict  a  majority 
of  country  women  to  too  severe  a  diet ;  for,  although  many  of  them 
may  have  fallen  victims  to  the  many  imprudences  they  commit,  there 
is  a  much  larger  number  who,  without  making  any  change  in  their 
ordinary  diet,  and  continuing  to  eat  cutlets,  bread,  and  all  sorts  of 
meats,  and  at  times  very  gross  food,  yet  get  up,  walk  about,  and  do 
their  customary  work,  in  two  days  after  child-birth,  without  any  bad 
effects  following  such  a  course. 

1243.  When  the  secretion  of  milk  has  taken  place  and  nothing 
unnatural  has  happened,  she  begins  to  return  by  degrees  to  her 
common  mode  of  hving ;  she  passes  gradually  from  soup  and 
panada,  and  semoulas  and  rice-milk,  to  boiled  eggs,  white  meats, 
fried  fish,  chops,  and  other  common  dishes  ;  so  that  in  from  eight  to 
ten  days  the  patient  has  no  more  need  than  any  body  else  of  being 
directed  in  relation  to  the  choice  of  her  food.  The  same  is  true  of 
her  drinks  ;  from  wine  and  water  she  proceeds  gradually  to  the  use 
of  beer  or  pure  wine  ;  in  fact  the  ptisans  may  be  laid  aside  after  the 
fourth  or  fifth  day.  Many  women,  however,  particularly  those  who 
cannot  or  will  not  suckle,  would  not  think  themselves  safe  were  not 
certain  infusions  and  medicines  prescribed  for  them  previous 
to  their  resuming  their  ordinary  regimen.  The  canne  de  Provence, 
the  arundo  phragmi/tes,  and  the  lesser  periwinkle,  especially  enjoy 
a  great  reputation  in  this  respect  with  the  public.  According  to 
the  statements  of  the  nurses  and  old  women,  the  decoction  of  these 
plants  is  a  powerful  means  of  repelling  the  milk.  The  woman  can- 
not dispense  with  its  use  if  she  wishes  to  avoid  tetters,  swellings, 
pains  and  all  the  consequences  of  the  lait  repandu,  a  common  bug- 
bear even  to  the  best  informed  women. 

The  ptisan  of  canne  is  too  insignificant  and  inoffensive  for  us  not 
to  prescribe  it  for  women  who  repose  any  confidence  in  it ;  the 
arundo  phragmytes  is  scarcely  more  active ;  but,  according  to  M. 
Desormeaux,  the  periwinkle  injures  the  stomach,  excites  the  pulse, 
and  ought  to  be  proscribed. 

1244.  Whether  these  drinks  have  been  made  use  of  or  not, 
almost  all  women  in  child  bed  desire  to  be  purged  before  they  get 
up  altogether  ;  they  then  use  sometimes  an  anti-lactic  purge,  and 
at  others  some  one  of  the  ordinary  cathartics.  Weiss's  whey  and 
sal  de  duobus  have  long  enjoyed  great  vogue  among  the  former  ; 
while  the  latter  most  generally  use  manna,  or  castor  oil,  sedlitz 
water,  or  decoction  of  senna. 

I  am  aware  that  it  would  be  dangerous  to  give  such  remedies 


MANAGEMENT  OF  LYING-IN  WOMEN.  577 

without  discrimination  to  all  women,  as  has  heretofore  been  done ; 
but  is  it  a  much  wiser  course  to  reject  them  all,  as  a  great  many 
physicians  of  the  present  day  recommend  to  be  done? 

If  the  accoucheur  fails  to  order  them,  he  exposes  himself  to  a 
thousand  reproaches,  which  I  am  sure  are  unjust,  but  which,  never- 
theless, cause  him  to  lose  the  confidence  of  his  patients  ;  should  the 
woman  be  seized  with  headach  or  rheumatism,  even  ten  years  after 
her  lying-in,  the  milk  is  the  cause  of  it ;  do  any  pimples,  or  efflor- 
escence on  the  skin,  any  fever,  abscess,  or  any  sort  of  inflammation 
make  their  appearance,  it  is  always  owing  to  the  milk  ;  and  upon 
reaching  a  certain  age  it  is  still  vi^orse  ;  if  the  features  lose  their 
freshness,  if  the  colour  of  the  cheeks  and  lips  fades,  if  the  eyes 
cease  to  be  brilliant  and  bright,  she  is  very  careful  not  to  accuse  the 
inexorable  sway  of  time,  but  she  refers  to  the  lait  repandu,  and  the 
blame  necessarily  falls  upon  the  physician  who  did  not  drive  out 
that  dreadful  milk  at  her  last  confinement ! 

Such  prejudices  would  doubtless  not  justify  the  employment  of 
purgatives,  were  they  as  dangerous  as  some  persons  choose  to  say  they 
are,  and  were  they  never  of  any  use  ;  but  such  are  not  the  facts. 
I  have  frequently  administered  them,  and  can  assert  that  I  have 
never  known  them  to  produce  any  bad  consequences ;  and  that,  in 
a  great  number  of  cases,  they  have  evidently  hastened  the  re-estab- 
lishment of  the  digestive  functions.  I  should  be  afraid  of  their  ac- 
tion where  the  tongue  is  red  and  lanceolate,  or  where  there  are  un- 
doubted signs  of  phlegmasia  in  the  abdomen  ;  I  believe  them  to  be 
of  no  use  where  the  strength  and  appetite  return  fairly  and  rapidly; 
but  where  the  tongue  is  broad,  whitish,  yellow,  or  greenish, 
the  mouth  bitter  and  clammy,  and  there  is  no  appetite,  even 
although  there  might  be  present  some  degree  of  fever,  tension  and 
sensibility  of  the  epigastrium,  a  gentle  purgative  I  have  often  found 
to  be  followed  by  the  very  best  effects.  I  have  seen  these  various 
symptoms  disappear  on  the  succeeding  day  in  most  cases,  and  the 
health  be  afterwards  restored  with  a  degree  of  promptitude  that  I 
had  had  no  reason  to  hope  for.  By  freeing  the  intestinal  canal  of 
the  mucous  deposit  with  /which  it  is  pasted  over,  the  purgatives 
brings  it  into  a  state  better  fitted  for  the  performance  of  its  func- 
tions ;  the  abundant  secretions  which  they  occasion  to  take  place 
from  the  villous  surface  of  the  digestive  passages  free  the  system 
from  substances  that  could  prove  hurtful  only,  and  impress  upon  the 
other  functions  a  sort  of  shock  by  which  nature  profits. 

I  prefer  the  factitious  sedlitz  water,  or  from  six  or  eight  drachms 
to  two  ounces  of  castor  oil;  their  effect  is  sufficiently  certain,  and  I 
3X 


578  MANAGEMENT  OF  LYING-IN  WOMEN. 

have  not  seen  them  produce  as  much  irritation  as  most  other  cTacu* 
ants. 

1243-  The  time  that  a  lying-in  woman  ought  to  remain  in  bed  is 
necessarily  very  variable,  and  the  nine  days,  the  period  &xed  by  the 
vulgar,  can  be  adopted  only  as  a  mean  or  general  term.  Five  or 
six  days  are  sometimes  sufficient ;  but  if  the  smyphyses  should  seem 
to  have  been  somewhat  strained,  the  womb  have  a  disposition  to  pro- 
lapse or  become  inverted,  or  the  health  appear  frail,  we  ought  to 
wait,  and  instead  of  eight  or  ten  days,  we  sboold  rather  require  her 
to  lie  still  for  two  weeks.  In  all  cases,  it  would  be  wrong  to  per- 
mit her  to  return  suddenly  to  her  usual  exercise,  as  some  practi- 
tioners allow  their  patients  to  do.  The  first  day  she  gets  up  she 
should  remain  half  an  hour  upon  a  sofa,  and  an  hour  the  next  day  ; 
the  third  she  may  take  a  few  steps  and  remain  out  of  bed  for  two 
or  three  hours  ;  and  during  the  following  days  she  should  consult 
her  strength  and  the  degree  of  fatigue,  as  the  rule  for  going  to  bed 
again.  Soon  after  this  she  can  go  down  and  take  a  few  turns  in 
the  garden,  or  in  the  yard ;  but  it  would  be  dangerous  to  go  to 
church  on  the  first  occasion  of  going  out  The  churches  are  ge- 
nerally large,  cold,  and  very  freely  ventilated.  In  what  is  called 
the'ur  Churching.,  the  women  should  keep  long  on  the  knees  ;  they 
are  sure  to  be  fatigued  before  they  go  out,  and  often  contract  there 
the  seeds  of  serious  diseases.  Real  religion  does  not  demand  such 
imprudences  :  the  woman  ought  to  recover  some  degree  of  strength 
before  she  goes  on  foot  to  present  herself  at  the  altar;  she  ought  first  to 
have  tried  her  strength  at  home,  and  make  sure  that  it  will  not  be  in- 
jurious to  her  to  go  out  into  the  open  air. 

1246.  Another  custom  that  the  physician  ought  to  watch  over  is 
the  baptismal  repast,  if  it  takes  place  within  the  first  ten  days  after 
child  birth.  In  this  family  feast  joy  is  not  forbidden  ;  they  laugh 
and  they  talk  ;  she  desires  to  hold  out  with  every  body  ;  the  father, 
the  mother,  the  godfather  and  godmother^  the  brothers,  sisters,  un- 
cles, aunts,  &c.  all  talk  to  her  in  turn.  She  only  takes  a  seat  at 
table  out  of  form,  to  be  sure,  or  to  make  more  sure  of  her  pru- 
dence she  keeps  her  bed  ;  all  the  guests  forbid  her  to  eat  or  drink 
any  thing  ;  but  in  the  mean  time  they  oblige  her  to  take  a  mouthful 
of  this  wine,  a  mouthful  of  that,  then  taste  of  thit  dish,  and  oftiat^ 
so  that  it  too  often  happens  that  at  the  close  of  the  day  she  finds 
herself  seized  with  symptoms  severe  enough  to  conduct  her  rapidly 
to  the  gates  of  death.  It  would  be  better,  therefore,  for  her  not  to 
be  present,  unless  it  be  beyond  the  tenth  or  fifteenth  day  ;  and  even 
tben,  she  ought  to  be  extremely  cautious. 


MANAGEMENT  OF  LYING-IN  WOMEN.  579 

The  Lochia,  the  After-pains,  and  the  Milk-fever,  three  of  the 
principal  natural  phenomena  of  a  lying-in,  now  deserve  our  particu- 
lar attention. 

1247.  The  term  Lochia  is  given  to  the  substances  that  escape 
from  the  vulva,  from  the  moment  of  the  delivery  of  the  secundines 
until  the  womb  has  recovered  its  normal  size  and  consistence  ;  the 
accoucheurs  distinguish  three  kinds  of  them  :  the  sanguine^  the 
serous  and  the  milky  or  purulent;  or  the  red,  the  clear,  and  the 
white.  The  first  are  observed  on  the  same  day  with,  and  on  the 
day  after  the  birth;  it  is  blood  nearly  pure.  The  second  appear  at 
the  end  of  twenty-four  or  thirty-six  hours,  are  formed  of  serum 
mixed  with  a  variable  quantity  of  blood,  and  do  not  last  beyond  the 
period  of  the  milk-fever.  The  third  succeed  these,  and  last  until 
the  fifteenth,  twentieth,  or  even  thirtieth  day,  and  are  produced  by 
the  suppurative  process  going  on  upon  the  internal  surface  of  the 
womb.  Nothing,  however,  is  more  variable  than  their  abundance 
and  duration:  the  red  lochia  may  cease  from  the  first  day  and  re* 
turn  on  the  fourth  ;  I  have  even  seen  them  reappear  on  the  ninth. 
Sometimes  the  purulent  lochia  do  not  appear  at  all,  and  in  other 
cases  they  last  so  long  that  it  is  difficult  to  distinguish  them  from  a 
leucorrhcea  ;  this  anomaly  is,  however,  very  easily  to  be  understood 
by  reflecting  for  a  moment  upon  the  cause  of  this  evacuation. 

Although  freed  from  the  child  and  the  after-birth,  the  womb  does 
not  immediately  recover  its  size  and  the  other  qualities  natural  to  it ; 
they  do  not  return  until  the  end  of  five,  six  or  eight  weeks,  a  period  at 
which  the  menses  reappear  for  the  first  time;  the  womb  indeed  always 
remains  a  little  larger  than  it  was  before  the  woman  became  preg- 
nant, and,  in  general,  the  more  so,  as  gestation  is  more  frequently 
repeated.  During  this  period  an  insensible  process  goes  on,  by 
means  of  which  the  uterine  parietes  are  disengorged  of  the  substan- 
ces they  had  imbibed.  These  fluids  are  directed  more  especially 
towards  the  cavity,  because  in  that  direction  the  tissue  is  less 
dense,  and  they  find  a  freer  issue.  As  long  as  the  great  uterine 
vessels  are  not  emptied,  blood  only  flpws ;  at  a  later  period  it  is 
serum  combined  with  the  detritus  of  the  ovum  and  the  mucous  se- 
cretions of  the  organ.  But  a  real  suppurative  irritation  is  soon 
established,  the  product  of  which,  analogous  in  some  sort  to  the  non- 
contagious discharges  from  the  urethra,  by  mixing  with  the  serosity 
and  mucus  furnished  by  the  womb,  constitute  the  white  lochia. 

The  lochia  require  only  cleanliness;  upon  theaccess  of  the  milk 
fever  they  sometimes  cease  to  flow,  or  at  least  sensibly  diminish  in 
quantity  ;  nevertheless  it  is  not  uncommon  to  see  these  two  pheno- 


580  MANAGEMENT  OF  LYING-IN  WOMEN. 

mena  proceeding  together  without  interfering  with  each  other. 
When  they  stop  either  before  or  after  the  milk  comes,  it  appears  to 
me  to  be  generally  useful  to  add  to  the  means  employed  to  recal 
them,  the  injection  of  emollient  or  slightly  detergent  fluids  into  the 
uterine  cavity. 

1248.  The  uterine  colics  or  affer-pains  commence  soon  after 
the  labour  is  over,  and  generally  cease  upon  the  appearance  of  the 
milk-fever,  and  rarely  last  longer  than  the  serous  lochia  :  they  are 
more  frequent  and  sharper  in  proportion  as  the  labour  has  been 
more  rapid  and  easy,  and  are  sometimes  strong  enough  to  fatigue 
the  woman  considerably  ;  being  produced  by  the  efibrts  of  the 
womb  to  contract,  it  is  quite  natural  that  they  should  be  stronger 
and  more  frequent  in  women  who  have  had  several  children,  than 
in  those  who  are  in  their  first  child  bed.  In  effect,  the  womb,  too 
rapidly  emptied  in  the  first  named  case,  does  not  contract  soon 
enough  to  prevent  the  formation  of  clots  in  its  cavity,  is  obliged  to 
contract  for  their  expulsion  as  often  as  they  are  reproduced,  and 
each  one  of  these  contractions  gives  rise  to  a  pain.  In  the  second, 
having  reacted  for  a  long  time  upon  the  ovum,  it  is  too  much  irri- 
tated at  the  close  not  to  resume  rapidly  its  natural  size,  and  not  permit 
the  blood  to  accumulate  within  its  cavity,  and  then  there  will  be  no 
clots,  no  contractions,  and  no  after-pains  ;  thus  the  presence  of 
clots  determines  the  contractions,  and  as  was  the  case  during  the 
labour,  the  contractions  occasion  the  after-pains.  I  ought,  how- 
ever, to  remark,  that  these  pains  must  also  vary  in  respect  to  their 
intensity,  the  constitution  of  the  patient,  and  the  circumstances; 
being  stronger,  for  example,  in  nervous  and  delicate  women,  when 
the  womb  is  already  sore,  and  in  a  state  approaching  to  inflamma- 
tion, than  in  those  who  are  in  an  opposite  condition,  though  in  fact 
the  contractions  are  similar  in  both  cases.  It  is  by  attending  to 
these  particulars  that  we  are  enabled  without  difliculty  to  explain 
their  great  severity  in  some  women  where  there  is  nothing  to  be  ex- 
pelled from  the  genital  organs,  and  their  mildness  in  others,  where 
they  coincide  with  the  escape  of  large  coagula;  and  how  it  happens, 
that,  instead  of  diminishing  after  the  second  day,  they,  on  the  con- 
trary, continue  to  augment  in  some  cases  until  the  third  and  fourth 
day,  &c. 

It  is  important  not  to  confound  them  with  an  incipient  metritis  or 
peritonitis,  which  however  is  a  pretty  difficult  matter  where  they 
reach  a  certain  extent  of  great  severity  ;  having  too  often  avoided 
making  this  distinction  is  the  reason  why  authors  differ  so  much 
on  the  subject  of  puerperal  peritonitis,  and  the  treatment  adapted  to 


MILK.FEVER.  581 

it ;  as  long  as  the  after-pains  are  clearly  intermittent,  and  during 
their  intervals  the  belly  is  not  sore,  while  there  is  no  fever  and  they 
have  not  been  ushered  in  with  a  chill,  there  is  nothing  to  fear  and 
nothing  to  do  ;  they  are  frequently  followed  by  a  pretty  severely 
painful  sensation  at  the  hypogastrium,  acceleration  of  the  pulse, 
thirst,  and  heat  of  the  skin,  and  notwithstanding,  are  not  followed 
by  any  serious  complaints.  But  we  must  in  such  cases  pay  atten- 
tion to  them,  and  not  forget  that  they  may  be  the  first  symptom  of  a 
mortal  disease. 

When  moderate  they  may  be  trusted  to  the  resources  of  the  eco- 
nomy, or  we  may  give  one  or  two  cups  of  a  weak  infusion  of  chamo- 
mile, which  rarely  fails  to  make  them  disappear  in  the  course  of  a 
day  or  two ;  otherwise,  it  is  sometimes  useful  to  prescribe  a  hip 
bath,  and  emollient  or  slightly  narcotic  injections  ;  to  exhibit  seda- 
tives or  antispasmodics  internally,  or  to  bleed  the  patient  once  or 
twice,  either  from  a  vein  or  by  topical  means,  while  at  the  same 
time  the  hypogastrium  is  covered  with  cataplasms,  and  this  accord- 
ingly as  the  woman  is  weak,  nervous,  or  plethoric ;  it  may  be  ne- 
cessary even  to  introduce  one  or  two  of  the  fingers  towards  the  os 
uteri  for  the  purpose  of  assisting  in  the  expulsion  of  a  clot  that  may 
adhere  too  strongly  ;  but  in  the  great  majority,  these  cases  require 
no  assistance. 

1249.  The  Milk-fever  generally  appears  on  the  third  day,  some- 
times on  the  first  or  second,  or  not  until  the  fourth,  fifth  or  sixth 
day  ;  I  have  seen  it  not  come  on  until  the  eighth,  in  a  young  wo- 
man at  the  Hospital  de  la  FacultS :  headach,  without  chills,  heat 
and  dryness  of  the  skin  are  its  common  precursors  ;  the  pulse  which 
is  at  first  small  and  hard  is  soon  developed  ;  the  breasts  grow  hard, 
swelled,  and  so  painful  in  the  course  of  a  few  hours,  as  to  interfere 
with  the  motions  of  the  arms  and  chest ;  first  a  moisture,  and  then 
a  sweat  succeed  this  stage  ;  the  pain  in  the  head  ceases  ;  the  fever 
abates  in  the  course  of  six,  eight,  ten,  twelve  or  twenty-four  hours, 
and  the  reaction  which  produces  the  milky  secretion  is  complcKd; 
but  the  breasts  remain  swelled  and  painful  much  beyond  this  period, 
especially  in  women  who  do  not  give  suck. 

While  the  fever  continues,  no  broths,  nor  potages,  nor  heating 
drinks  should  be  given.  Should  it  be  too  high,  an  attempt  to  mo- 
derate its  violence  should  be  made  by  means  of  a  small  bleeding. 
But  in  general  it  requires  only  tlie  hygieinic  treatment  pointed  out 
higher  up.  The  coming  of  the  milk  is  pretty  often  preceded  v/ith 
the  suspension,  or  at  least  a  sensible  diminution,  of  the  lochial  dis- 
charges, which  soon  return  to  their  natural  course.     Sometimes 


582  MANAGEMENT  OF  LYING-IN  WOMEN. 

these  two  phenomena  seem  to  have  no  influence  upon  each  other, 
the  lochia  do  not  appear  again  at  all  after  the  milk-fever  is  gone  off. 
For  an  account  of  lactation  in  general,  the  diet  of  the  foetus,  the 
choice  of  a  nurse,  the  diseases  of  the  breast  and  nipple;  for  the  his- 
tory of  fistulas,  whether  recto-vaginal  or  vesico-vaginal,  or  other 
serious  lesions  which  are  the  effect  or  consequence  of  certain  la- 
borious labours,  1  can  only  refer  to  the  general  treatises  on  Physi- 
ology, Medicine,  or  Surgery  that  treat  upon  them  ;  particularly 
those  of  MM.  Richerand,  Magendie,  Adelon,  Leger,  Sabattier, 
Boyer,  &c.  and  to  the  excellent  articles  by  M.  fiesormeaux  in  the 
Dictionnaire  de  Medecine.  But  there  are  certain  accidents  of  a 
less  redoubtable  kind,  concerning  which  I  cannot  dispense  with  say- 
ing a  few  words  in  this  place. 

1250.  Complete  or  partial  Inversion  of  the  womb  is  recognised 
by  the  reddish  or  livid  tumour  which  projects  into  the  vagina  or 
vulva,  by  the  absence  of  the  uterine  globe  above  the  pubis,  and  by  the 
pains  and  syncope  experienced  by  the  woman,  &c.;  although  none 
but  the  grossest  ignorance  could  confound  an  inversion  of  the  womb 
with  a  polypus  in  that  organ,  yet  men  are  sometimes  seen,  even  at 
Paris,  to  commit  this  mistake,  even  though  they  are  clothed  with 
the  title  of  physicians.  Haste  should  be  made  to  reduce  the  dis- 
placed organ.  For  this  purpose  the  woman  should  be  so  placed 
that  her  hips  may  be  higher  than  her  breast ;  then  the  hand  being 
furnished  with  a  piece  of  fine  linen  spread  vpith  cerate,  the  exter- 
nal tumour  should  be  compressed  gradually  and  without  shocks, 
and  in  a  steady  manner,  and  at  all  points,  pushing  it  up  along  the 
axis  of  the  straits  until  it  has  regained  its  natural  situation.* 

1251.  The  Descent  of  the  womb,  which  is  pretty  often  met  with  in 
the  early  periods  of  a  confinement,  in  women  who  have  a  very  large 
pelvis,  relaxed  tissues,  a  lacerated  perineum,  or  in  those  who  make 
improper  exertions,  scarcely  requires  any  thing  after  the  reduction 
except  rest  and  a  horizontal  posture  ;  it  is  allowable  only  to  add 
soHb  astringent  or  styptic  lotions,  the  use  of  small  rags  moistened 
with  red  wine,  for  example,  in  cases  where  there  is  no  irritation. 
Pessaries  cannot  be  made  use  of  until  a  much  later  period. 

1262,  The  Antejlexion  and  Retroflexion,  that  is  to  say,  the  state  in 
which  the  womb  bends  like  an  elbow  at  right  angles,  so  that  its 
fundus  comes  to  rest  upon  the  sacro-vertebral  angle  or  behind  the 
pubis,  a  disease  very  well  described  by  M.  Ameline  in  his  disserta- 


*  For  a  very  good  treatise  oo  inversion  of  the  uterus  in  general,  see  a  thesis 
maintatoed,  Dec.  1, 1828,  at  the  Faculty  de  Paris,  by  M.  Ferrance-Demissols. 


MANAGEMENT  OP  LYING-IN  WOMEN.  583 

tion,  and  an  instance  of  which  in  the  dead  body  was  shown  to  me 
by  M.  Comte,  would  be  recognised  by  the  same  symptoms  as  the 
anteversion  and  retroversion,  and  would  require  nearly  the  same 
kind  of  treatment. 

1253.  Laceration^  of  the  perineum  generally  get  well  of  them- 
selves, with  the  assistance  of  the  hip  bath,  by  avoiding  all  motion, 
and  by  obliging  the  woman  to  keep  on  her  side,  so  that  the  pus  and 
lochia  may  not  stagnate  in  the  wound.  They  generally  cicatrise 
more  or  less  completely  from  the  anus  towards  the  commissure  of 
the  pudendum.  The  perineum  may  be  perforated  through  and 
through,  and  the  cure  not  be  rendered  any  more  difficult, 
provided  that  the  anal  and  vulvar  edges  remain  unhurt.  I  saw 
a  case  of  this  perforation  produced  by  the  passage  of  a  large 
child,  which  was  entirely  cured  by  the  eighteenth  day,  and  did  not 
hinder  the  woman  at  all  in  her  subsequent  labours.  In  some  cases, 
however,  it  is  necessary  to  cut  the  bridles,  apply  the  caustic,  and 
take  up  certain  points  with  the  needle,  &c.  but  then  the  disease  re- 
turns under  the  domain  of  ordinary  surgery,  and  cannot  be  regard- 
ed as  one  of  the  simple  consequences  of  child  birth.  I  shall  say 
the  same  of  lacerations  of  the  vagina,  of  the  cervix,  body,  and  fun- 
dus of  the  womb;  of  rupture  of  the  psoas  muscles,  of  the  rectus 
muscles  and  those  of  the  sternum,  observed  at  the  Paris  Mater- 
nite  by  Mesdames  Boivin,  Lachapelle,  and  by  M.  Comte.  Upon 
this  subject  the  excellent  memoirs  by  Madame  Lachapelle  may  be 
consulted,  and  in  this  book  the  article  on  extra-uterine  pregnancy. 
I  have  not  treated  of  descents  of  the  ante-version  and  retro- version 
as  diseases,  because  they  are  observed  solely  in  women  who  are 
pregnant ;  lastly,  in  treating  of  hemorrhage,  I  said  nothing  relative 
to  transfusion  of  the  blood,  practised  anew  in  these  latter  times  by 
Messrs  Blundell,  Doubleday,  Waller,  Brigham,  Boyle,  Brown, 
&c.  because  it  is  not  yet  proved  that  an  operation  so  dangerous 
ought  really  to  be  adopted  by  wise  and  circumspect  practitioners. 

1254.  Infiltration  of  the  external  genitals  may  go  to  the  extent 
of  closing  the  passage  of  the  vulva,  and  consequently,  of  prevent- 
ing the  discharge  of  the  lochia.  If  the  swelling  be  purely  lympha- 
tic, and  not  painful,  it  will  disappear  upon  making  a  few  pretty  deep 
punctures  upon  the  internal  surface  of  the  pudendum.  Where  there 
is  sensibility  and  any  signs  of  inflammation,  recourse  should  be  had 
to  baths,  embrocations,  emollient  cataplasms,  and  even  to  leeches,  if 
the  case  require  it. 

1 255.  The  Thrombus  of  the  labia  pudendi,  which  was  noticed  by 
Levret,  forgotten  by  most  of  the  modern  writers,  pretty  well  describ- 


584  MANAGEMENT  OF  LYING-IN  WOMEN. 

ed  by  Dr  Dewees,  and  of  which  I  have  seen  seven  or  eight  oases, 
may  appear  at  the  moment  the  head  is  engaging  in  or  clearing  the 
inferior  strait,  and  even  in  the  two  first  days  after  the  birth  of  the 
child,  as  in  the  case  lately  published  by  M.  Wintringer.  The  tu- 
mour sometimes  involves  both  of  the  labia ;  more  frequently  only 
one  is  affected.  Although  in  some  cases  it  is  from  the  size  of  a  nut 
to  that  of  a  hen's  egg,  it  is  also  found  to  assume  in  other  cases 
much  greater  dimensions  ;  it  rarely  disappea>s  by  resolution,  and 
some  women  suffer  from  it  horribly.  Leeches  and  poultices  are 
generally  insufficient  for  its  cure,  but  I  have  always  found  it  to  be 
promptly  dissipated,  and  without  any  bad  consequence,  after  a  large 
and  deep  incision. 


THE  END. 


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